Dean's aggregator

Finding opposing views (and surprises) on Twitter

2012-01-30T12:47:00.000Z

So, I thought it would be good to look at ways to find people with opposing views. It is easy to fall into a social media niche where you only talk to people who share the same views as yourself.

I picked a topic which is highly debated #NHSbill to see how easy it would be find individuals. I've been building some classification software that I thought I'd try it out on.

I looked through all the entries and found plenty apparently opposing the bill but had difficulty finding views in support of the NHS reforms. I started thinking maybe I should find another topic that's more balanced as it would be hard to classify #NHSbill tweets. However, I did spot this one

from @felicitydeane.

But, just below that tweet, a few days previously, I noticed a tweet about Molly from Kenya.

Molly lives in a slum in Nairobi, Kenya and was given a small video camera by the World Food Programme. She has a YouTube channel with excerpts from what she filmed.

Kenya is something that has great importance for me as we have been involved with a Kenyan charity for orphaned children in west Kenya called Mercy Rescue Trust. I hadn't heard about Molly's video channel though.

A good find I thought. Wait! That's an example of the reason for looking outside your local social media network.

This type of serendipity is important for social media. I realise it is well documented before and seen by many as a great reason for building a network of contacts. It struck me as a particularly good example and thought I'd share it.

Gold Standards Framework

2012-01-27T14:00:00.000Z

Had an update on the end of life management policies in Cornwall through the Gold Standards Framework (GSF).

"[GSF] was first piloted in Yorkshire in 2001 in Phase 1, followed by a national phased programme supported by the NHS, Macmillan and more recently the DH End of Life Care Programme. An intrinsic element of the work has been the internal and external evaluations, originally using questionnaires and more recently the on-line After Death Analysis audit tool, plus several independent University based evaluations, which contributed to the further development of the work. National spread was enabled through a strategic national cascade plan with the GSF Central Team supporting local facilitators, enabling best implementation of the work, overseeing training and audit plus developing further adaptations and resources."

Recent progress in Cornwall includes the adoption of the same version 12 of the Liverpool integrated care pathway for the dying patient (LCP) in primary care, secondary care and care homes. There is ongoing negotiation about the implementation of the GSF in Cornwall.

These approaches both originated from examples of best practice in the NHS. The LCP from the NHS Beacon Programme in 2001/2 [1] and the GSF at a similar time being taken up by the National Council for Palliative Care from 2003. They are both widely adopted. I'm looking forward to reading more about the evaluations they have undergone [2,3] and the particular challenges of evaluating this type of quality improvement [4]. Do they make a difference?[5]

1. Ellershaw J, Ward C. Care of the dying patient: the last hours or days of life. BMJ 2003 Jan;326(7379):30-34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12511460

2. Costantini M, Ottonelli S, Canavacci L, Pellegrini F, Beccaro M. The effectiveness of the Liverpool care pathway in improving end of life care for dying cancer patients in hospital. A cluster randomised trial. BMC Health Serv Res 2011;11:13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21261949

3. Duffy A, Payne S, Timmins F. The Liverpool Care Pathway: does it improve quality of dying? [corrected]. Br J Nurs 2011 Sep;20(15):942-946. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21841661

4. Pugh EJ, McEvoy M, Blenkinsopp J. Use of the proportion of patients dying on an End of Life Pathway as a quality marker: considerations for interpretation. Palliat Med 2010 Jul;24(5):544-547. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20501514

5. Kinley J, Froggatt K, Bennett MI. The effect of policy on end-of-life care practice within nursing care homes: A systematic review. Palliative Medicine 2012 Jan; Available from: http://www.ncbi.nlm.nih.gov/pubmed/22218097

Irrational thinking

2012-01-26T14:00:00.000Z

Great talk at the Truro Grand Round today on irrational thinking, cognitive bias, and generally things psychological that affect medical decisions and the behaviour of healthcare professionals.

It included this classic video of selected attention. Basically it was introduced as follows - "There is a gender difference in detailed attention. Watch this video very carefully and count exactly how many times the white team pass a basketball to each other. They will move around a lot so count carefully and we'll see who does better - male doctors or female doctors."

About half of those in the room had excellent sensory attention and the other half, including me, did not notice one thing in particular.

Other topics covered were:
The Monty Hall problem
Thinking, Fast and Slow. Daniel Kahneman
The hidden Dalmatian dog illusion

Science, Business, Politics or naivety in telehealth / telecare

2012-01-25T11:00:00.000Z

Would the telehealth / telecare community and the evaluation team of the Whole System Demonstrator Programme please get their act together? If you are sceptical then be scientific. If you are frustrated at the slow uptake of technologies then be political. Don't try to mix the two.

The UK Department of Health (DH) funded research on telehealth and telecare, the Whole System Demonstrator programme, had its 'headline findings' published in December 2011. A press release described it as

"The Whole System Demonstrator (WSD) programme is the largest randomised control trial of telehealth and telecare in the world, involving 6191 patients, 238 GP practices across three sites, Newham, Kent and Cornwall. WSD was set up to look at cost effectiveness, clinical effectiveness, organisational issues, effect on carers and workforce issues. It focused on three conditions, diabetes, COPD and coronary heart disease. The programme will provide a clear evidence base to support important investment decisions and show how technology supports people to live independently, take control and be responsible for their own health and care."

On 19th January 2012 Paul Birstow, Minister for Care Services, announced a Concordat with industry "to enhance the lives of three million people over the next 5 years by accelerating the roll-out of telehealth and telecare in the NHS and social care".

The headline findings of the Whole System Demonstrator, described by DH as one of the most complex trials it has undertaken designed to answer the question "Does the use of technology as a remote intervention make a difference?" are impressive.

"The early indications show that if used correctly telehealth can deliver a 15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs. More strikingly they also demonstrate a 45% reduction in mortality rates."

However, there are a number of questions about the study:

45% reduction in mortality rates! Really? So why is the data that has been hanging around for over a year not being scrutinised?
How come the DH can publish the results of a large Randomised Controlled Trial without peer review, quoting Relative Risk Reductions, no drop-out rates, and no confidence intervals? (Prof Trish Greenhalgh).
What incentives did the general practices have for putting the patients into the trial?
Apparently the detailed research is undergoing 'peer-review' so I wonder what the final report will look like. Is it presumptuous to talk about 'watershed' moments and "There's been more pilots in this space than British Airways. What we need to do now is drive forward at scale." Are you going to look at the evidence or not?
What is going to be presented in March 2012 at the Kings Fund meeting?
The last data was collected in September 2010, the results were asked for at a Kings Fund meeting on telehealth in March 2011 where the design was presented along with recruitment demographics and research themes. Then, later in March, the trial design was submitted (and published in August 2011) with an endnote saying that "In practice it was found that the majority of patients were exposed to one technology alone, and therefore the simpler design was eventually adopted." When was that 'eventually'? Looks like post-hoc. It is common practice to submit trial designs before recruiting patients. The GP practices were clearly biased to the fact that they thought the telehealth / telecare would be beneficial and it shouldn't be withheld from some patients.
Why is the Whole System Demonstrator variously described as a Randomised Controlled Trial, a field trial, a complex evaluation among other things?
The rumour from the test sites was that about 10% of the benefit was perhaps from the technology. Presumably the rest was from the engagement with the health professionals. If it is not all about the technology why does it appear the thrust of the investment conclusion is towards equipment? Healthcare staff will require new competencies for remote and asynchronous healthcare if they are to provide that 90% benefit.

I have a prior belief that telehealth and telecare is effective. I suspect it would be useful for certain types of patients but it may not be beneficial for all. For some it may be harmful by leaving them remotely managed but requiring face-to-face care. I'd like to be able to answer accurately the patient who asks me "so this remote monitoring equipment is going to work for me is it?" or the Medical Director who asks "Hey you're a techie type aren't you? How much of our budget should be assigned to this telehealth / telecare stuff?" I'd like to answer those uncertainties with some data.

See also:
Storify of Twitter discussion and links about #WSD
Paper by Davies & Newman on evaluating telecare and telehealth interventions including a description of 'pragmatic RCT'

Stroke mimics

2012-01-20T14:00:00.000Z

Case presentation and discussion of stroke mimics at the lunchtime meeting. Can't remember the exact details of the case but it was someone presenting with acute ischaemic stroke being considered from thrombolysis - the learning point was "but what about those conditions that may present as stroke but are not?"

There was a nice presentation about the different presentations and how they may be differentiated clinically.

This is an important issue. [1-3]

Found a good summary lecture online - Stroke Differential Diagnosis - Mimics and Chameleons.

1. Förster A, Griebe M, Wolf ME, Szabo K, Hennerici MG, Kern R. How to identify stroke mimics in patients eligible for intravenous thrombolysis?. Journal of Neurology 2012 Jan; Available from: http://www.ncbi.nlm.nih.gov/pubmed/22231865
2. Winkler DT, Fluri F, Fuhr P, Wetzel SG, Lyrer PA, Ruegg S, Engelter ST. Thrombolysis in stroke mimics: frequency, clinical characteristics, and outcome. Stroke 2009 Apr;40(4):1522-1525. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19164790
3. Artto V, Putaala J, Strbian D, Meretoja A, Piironen K, Liebkind R, Silvennoinen H, Atula S, Häppölä O. Stroke mimics and intravenous thrombolysis. Ann Emerg Med 2012 Jan;59(1):27-32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22000770

LIFENOX study - TED stockings good enough for VTE prophylaxis in medical patients?

2012-01-13T14:00:00.000Z

Good discussion at the lunchtime meeting today about the recent study, reported in the NEJM, on the use of low-molecular weight heparin vs. placebo in medically ill patients - the LIFENOX study.[1]

"The use of enoxaparin plus elastic stockings with graduated compression, as compared with elastic stockings with graduated compression alone, was not associated with a reduction in the rate of death from any cause among hospitalized, acutely ill medical patients."

All the patients (who were medical inpatients with CCF or severe infection with one risk factor for venous thromboembolism or had a diagnosis of cancer) had TED stockings and either enoxaparin or placebo. The authors wondered if the TED stockings did a good enough job of preventing VTE.

A Now@NEJM blog about the study provides a good overview and which points out:

"Although elastic stockings with graduated compression have been shown to be effective in reducing the risk of deep-vein thrombosis in moderate-risk surgical patients and other medical patient populations, the use of stockings did not prevent the occurrence of deep-vein thrombosis in patients recuperating from severe, disabling stroke who were participants in the Clots in Legs or Stocking after Stroke trial (CLOTS)."

Another interesting point about the study is that it involved sites less commonly seen in publications - China, India, Korea, Malaysia, Mexico, the Philippines, and Tunisia.

1. Kakkar AK, Cimminiello C, Goldhaber SZ, Parakh R, Wang C, Bergmann J-F. Low-molecular-weight heparin and mortality in acutely ill medical patients. N. Engl. J. Med. 2011 Dec;365(26):2463-2472. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22204723

Time to retire the PDSA cycle?

2012-01-10T13:28:00.002Z

We are told that the Deming (or Shewhart) cycle of Plan-Do-Study-Act, originally described in 1950 as a quality improvement tool, can help in the following ways:

"Using PDSA cycles enables you to test out changes before wholesale implementation and gives stakeholders the opportunity to see if the proposed change will work." NHS Institute of Innovation and Improvement

"The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change." Institute for Healthcare Improvement

It is sold as a 'scientific method' dating back to Galileo and Francis Bacon.

I beg to differ.

I think it is not fit for its wider purpose promoted by its proponents as part of a culture of overall quality improvement in healthcare.

It is good at improving the issue that it is targetting but only when it is in isolation. Seeing healthcare as an industrial process that consists of conveyor belts of treatment pathways that are separate from each other is not how I see the world. This PDSA cycle is good for manufacturing where the process can be controlled and isolated but healthcare is more complex. There are uncertainties about which patients should be on which pathways. Patients have more than one condition or require more than one treatment and the simple view of a PDSA cycle (which is good at improving car manufacture) is too simple for the real world of clinical medicine. Yes it can be used as a strategy for a single focussed task in medicine but it is not fit for using more widely as it is too dumb a tool for the job. In short it is a good 'in vitro' tool but not so good an 'in vivo' tool.

Also, the PDSA cycle may have unintended consequences. If, for example, on an emergency medicine unit we use PDSA cycles to improve our quality of care for community-acquired pneumonia patients this may have the unintended consequence of reducing quality (by de-prioritising) in other conditions such as acute stroke or anything that does not have its own PDSA cycle.

Is it time to recognise PDSA cycles for what they are; useful tools for focussed tasks but too simple an intervention to be used widely in medicine where it may do more harm than good?

Bisphosphonates improve joint replacements - retrospective GPRD cohort

2011-12-12T14:54:00.001Z

A retrospective cohort study on joint replacements using the UK's General Practice Research Database (GPRD) is published in the BMJ.[1]

Researchers from Oxford looked at the records of almost 42,000 patients who had a knee or hip replacement and found that 1912 of them had bisphosphonates. They concluded,

"In patients undergoing lower limb arthroplasty, bisphosphonate use was associated with an almost twofold increase in implant survival time. These findings require replication and testing in experimental studies for confirmation."

It is important to remember that this is a non-randomised study and is observational in nature. Controversy exists on how this type of data should be used and, as the researchers suggest, it requires experimental study.

With the recent news of the potential release of routine NHS data these types of observations will become more frequent. Should we act on them in the interests of improving quality or consider them hypotheses that require testing?

1. Prieto-Alhambra D, Javaid MK, Judge A, Murray D, Carr A, Cooper C, Arden NK. Association between bisphosphonate use and implant survival after primary total arthroplasty of the knee or hip: population based retrospective cohort study. BMJ 2011 Dec;343(dec06 1):d7222-d7222. Available from: http://www.bmj.com/content/343/bmj.d7222

MedEdMOOC organisers' meeting 11th Dec 2011

2011-12-11T23:46:00.001Z

Had a good Google+ hangout and parallel Twitter chat about #MedEdMOOC today and looks like there's a creative group that has come together. Documentation has been updated and a new organisers-only area started so that some key decisions can be made. Still looking at an April / May 2012 course of about 5 - 6 weeks.

Date Sunday 11th December 21:00 GMT (worldtime here) - poll was here
On G+ and Twitter using the hashtag #MedEdMOOC
Agenda (and minutes)

governance structure

decided organiser group with asynchronous loose consensus
organiser Google doc (request an invite)
work on it until second week of January have another meeting

topic list

to work on in the organiser doc

research agenda

not discussed

dates

April looks good

requirements (platforms, technologies, speakers etc.)

Multimedia archiving platform such as Blackboard Collaborate

Time	From User	Tweet
Sun, 11 Dec 2011 23:09:04 +0000	phcsig	RT @bronwynah: #CochraneColloquium in NZ 2012 http://t.co/fnMw9y2f #EBP #mededmooc
Sun, 11 Dec 2011 23:03:27 +0000	dean_jenkins	@claireOT can you DM me your Google login email so that I can add you to the organisers' document for #MedEdMOOC?
Sun, 11 Dec 2011 22:37:10 +0000	bronwynah	@BrianSMcGowan great idea, many speech path / disability links & resources that can be pulled in, also networks #mededmooc #slpeeps etc
Sun, 11 Dec 2011 22:35:53 +0000	dean_jenkins	#MedEdMOOC organisers' Google Doc. http://t.co/GdzAjqYc #mededmooc
Sun, 11 Dec 2011 22:35:18 +0000	dean_jenkins	Have set up an organisers' Google Doc but need to have email addresses to invite you in. #mededmooc
Sun, 11 Dec 2011 22:18:51 +0000	croakeyblog	RT @bronwynah: #CochraneColloquium in NZ 2012 http://t.co/fnMw9y2f #EBP #mededmooc
Sun, 11 Dec 2011 22:16:27 +0000	BrianSMcGowan	Great lessons in planning out the "24 hours of #mededMOOC" - do you find 24 spkrs? seek out 24 topics? leverage different regions?
Sun, 11 Dec 2011 22:11:00 +0000	dean_jenkins	@helen_otuk suggests maybe 3 regional organising groups for the 24 hour session. #mededmooc
Sun, 11 Dec 2011 22:10:03 +0000	dean_jenkins	24 hour global MedEdMOOC tour will reflect the 5 or 6 topic weeks that would follow. ... possibly #mededmooc
Sun, 11 Dec 2011 22:08:47 +0000	dean_jenkins	Move the topic discussion into the organisers' Google doc to tie it down from the big list. #mededmooc
Sun, 11 Dec 2011 22:07:11 +0000	dean_jenkins	@lewismal cheers! #mededmooc
Sun, 11 Dec 2011 22:06:23 +0000	lewismal	I need to go now and attend to my kids. I check back. #Mededmooc
Sun, 11 Dec 2011 22:03:51 +0000	claireOT	RT @dean_jenkins: Talking about a world #MedEdMOOC day with different sessions covering all timezones! Ambitious. Like World OT day. #mededmooc
Sun, 11 Dec 2011 22:02:38 +0000	lewismal	@lewismal See http://t.co/PqDQPZE1 #Mededmooc
Sun, 11 Dec 2011 22:01:16 +0000	lewismal	A wiki is good home for a event #Mededmooc
Sun, 11 Dec 2011 22:00:26 +0000	lewismal	Virtual international day of the midwife also a model. The original I think from @sarahstewart #Mededmooc
Sun, 11 Dec 2011 21:59:22 +0000	dean_jenkins	Brian will research a 'home' like Moodle. #mededmooc
Sun, 11 Dec 2011 21:58:47 +0000	lewismal	By the way this tends to be a good time for online meeting for me #Mededmooc
Sun, 11 Dec 2011 21:56:08 +0000	lewismal	RT @dean_jenkins: Elluminate (now Blackboard Collaborate) would be good. Archiving a good feature. #Mededmooc
Sun, 11 Dec 2011 21:55:24 +0000	BrianSMcGowan	like 'battle to the death' session? RT @lewismal: We could have series of eliminate sessions ... #Mededmooc
Sun, 11 Dec 2011 21:55:03 +0000	dean_jenkins	Elluminate (now Blackboard Collaborate) would be good. Archiving a good feature. #mededmooc
Sun, 11 Dec 2011 21:52:34 +0000	dean_jenkins	24hour event would be a good way of including a lot of points of view. Platform will be key. Twitter back channel as well. #mededmooc
Sun, 11 Dec 2011 21:52:30 +0000	lewismal	We could have series of eliminate sessions gaps filled by tweet chats, other online events over 24 hrs #Mededmooc
Sun, 11 Dec 2011 21:48:56 +0000	Helen_otuk	like it... RT @lewismal: A 24 hour event would be good team building & gr8 marketing #Mededmooc
Sun, 11 Dec 2011 21:48:14 +0000	dean_jenkins	RT @lewismal: A 24 hour event would be good team building & gr8 marketing #mededmooc
Sun, 11 Dec 2011 21:48:12 +0000	BrianSMcGowan	+1 RT @lewismal: A 24 hour event would be good team building & gr8 marketing #Mededmooc
Sun, 11 Dec 2011 21:47:13 +0000	kirstyes	RT @dean_jenkins: Talking about a world #MedEdMOOC day with different sessions covering all timezones! Ambitious. Like World OT day. #mededmooc
Sun, 11 Dec 2011 21:47:02 +0000	lewismal	A 24 hour event would be good team building & gr8 marketing #Mededmooc
Sun, 11 Dec 2011 21:45:37 +0000	lewismal	Stages formation, concept, plan, promote, run, evaluate, sustain #Mededmooc
Sun, 11 Dec 2011 21:44:40 +0000	dean_jenkins	There'll be a social media resource booth at Alliance meeting. #mededmooc
Sun, 11 Dec 2011 21:43:42 +0000	dean_jenkins	@helen_otuk talking about a social media 'surgery' #mededmooc
Sun, 11 Dec 2011 21:41:15 +0000	dean_jenkins	6 weeks to get a group together. 6 months to get the MOOC up. (Brian's suggested rule of thumb from what we've done so far) #mededmooc
Sun, 11 Dec 2011 21:41:05 +0000	amcunningham	RT @dean_jenkins: Talking about a world #MedEdMOOC day with different sessions covering all timezones! Ambitious. Like World OT day. #mededmooc
Sun, 11 Dec 2011 21:40:03 +0000	lewismal	RT @dean_jenkins: @amcunningham w00t! #Mededmooc
Sun, 11 Dec 2011 21:39:55 +0000	amcunningham	RT @dean_jenkins: Can't see how to easily record a Google Hangout. My sound recorder (on Linux) just records my Mic. #mededmooc
Sun, 11 Dec 2011 21:39:48 +0000	dean_jenkins	Learnt a lot in the last 6 weeks. Would be good to document it and present it within various disciplines. #mededmooc
Sun, 11 Dec 2011 21:39:21 +0000	dean_jenkins	Jumping around a bit. Requirements - link to other groups like Physios and Cochrane. #mededmooc
Sun, 11 Dec 2011 21:37:54 +0000	Helen_otuk	#mededmooc health aspects makes mededmooc different from other MOOCs
Sun, 11 Dec 2011 21:35:43 +0000	dean_jenkins	Talking about a world #MedEdMOOC day with different sessions covering all timezones! Ambitious. Like World OT day. #mededmooc
Sun, 11 Dec 2011 21:34:52 +0000	dean_jenkins	@amcunningham w00t! #mededmooc
Sun, 11 Dec 2011 21:34:46 +0000	BrianSMcGowan	Can we launch #mededmooc with a 24 hours of learning...keeping a G+ hangout going for 24 hours + twitter backchannel...w/ 24 speakers...
Sun, 11 Dec 2011 21:34:29 +0000	dean_jenkins	@lewismal agreed - we're talking about using a GDoc to coordinate and record the decision making. #mededmooc
Sun, 11 Dec 2011 21:34:20 +0000	amcunningham	@dean_jenkins go with flow! #mededmooc
Sun, 11 Dec 2011 21:32:27 +0000	BrianSMcGowan	Governance: First mover with broadly communicated dates. Learning: Keep track of plans that were deprioritized (and why). #mededMOOC
Sun, 11 Dec 2011 21:32:26 +0000	dean_jenkins	Healthcare ethics need to be considered. #mededmooc
Sun, 11 Dec 2011 21:29:57 +0000	lewismal	Seems with timezones, we need to make use of asynchonist decision making. Move a motion, get agreement in doc #Mededmooc
Sun, 11 Dec 2011 21:28:41 +0000	dean_jenkins	"Can't do everything in a pilot." Bronwyn #mededmooc
Sun, 11 Dec 2011 21:28:26 +0000	dean_jenkins	Governance - record those ideas that aren't prioritised so that we can return to them. Limited resources dictates. #mededmooc
Sun, 11 Dec 2011 21:26:19 +0000	dean_jenkins	Set dates in the open document, flag decisions, those available can meet and coordinate. Avoid excluding. #mededmooc
Sun, 11 Dec 2011 21:23:24 +0000	lewismal	We need to build agreement, shared purpose and a critical mass in a team #Mededmooc
Sun, 11 Dec 2011 21:21:43 +0000	lewismal	@dean_jenkins Agree with tweet #Mededmooc
Sun, 11 Dec 2011 21:19:13 +0000	dean_jenkins	Working on governance. Probably first mover advantage plus consensus where possible. #mededmooc
Sun, 11 Dec 2011 21:17:59 +0000	lewismal	http://t.co/5y4XiE3u #Mededmooc
Sun, 11 Dec 2011 21:17:17 +0000	dean_jenkins	Just getting started. #mededmooc
Sun, 11 Dec 2011 21:14:23 +0000	lewismal	Audacity software I think is used by @downes. It is free and moderatly easy to use. #Mededmooc
Sun, 11 Dec 2011 21:13:26 +0000	dean_jenkins	Can't see how to easily record a Google Hangout. My sound recorder (on Linux) just records my Mic. #mededmooc
Sun, 11 Dec 2011 21:10:02 +0000	dean_jenkins	@lewismal any suggestions as to how to do that? #mededmooc
Sun, 11 Dec 2011 21:09:08 +0000	dean_jenkins	Waiting for a few more participants. #mededmooc
Sun, 11 Dec 2011 21:08:51 +0000	Helen_otuk	Have fun. RT @dean_jenkins @amcunningham you in the pub then after your game? #mededmooc
Sun, 11 Dec 2011 21:07:50 +0000	dean_jenkins	@bronwynah are you Uni Queensland? I think I've added you into the G+ circle. #mededmooc
Sun, 11 Dec 2011 21:06:56 +0000	lewismal	Can we set up audio recording archive, it may help make decisions #Mededmooc
Sun, 11 Dec 2011 21:06:36 +0000	dean_jenkins	@amcunningham you in the pub then after your game? #mededmooc
Sun, 11 Dec 2011 21:05:16 +0000	dean_jenkins	@lewismal OK will try and retweet things for you! #mededmooc
Sun, 11 Dec 2011 21:04:15 +0000	lewismal	I'm here but have low bandwidth also can,t join G hangout from iPad I discover. Carry on I will follow on twitter #Mededmooc
Sun, 11 Dec 2011 21:03:22 +0000	dean_jenkins	@helen_otuk and @dean_jenkins on http://t.co/rHMeRiLE for chat on #mededmooc
Sun, 11 Dec 2011 21:02:44 +0000	dean_jenkins	@amcunningham boo ... any points or you happy to go with the flow? #mededmooc
Sun, 11 Dec 2011 21:01:57 +0000	amcunningham	#mededmooc sorry not going to make the meeting!
Sun, 11 Dec 2011 21:00:45 +0000	dean_jenkins	Who's here then? #mededmooc
Sun, 11 Dec 2011 21:00:21 +0000	dean_jenkins	G+ on http://t.co/rHMeRiLE if you're not in my MedEdMOOC circle then let me know. #mededmooc
Sun, 11 Dec 2011 20:56:49 +0000	dean_jenkins	Setting up a G+ hangout for http://t.co/is6rCtnm #mededmooc
Sun, 11 Dec 2011 20:02:05 +0000	dean_jenkins	#MedEdMOOC chat in 1 hour. Start on Twitter then on to G+ probably. @amcunningham might be late :-)
Sun, 11 Dec 2011 14:01:47 +0000	Helen_otuk	RT @dean_jenkins: Audioboo: #MedEdMOOC chat today 11th December at 21:00 hrs GMT http://t.co/hVJB1yy7 #mededmooc
Sun, 11 Dec 2011 12:58:43 +0000	dean_jenkins	Audioboo: #MedEdMOOC chat today 11th December at 21:00 hrs GMT http://t.co/hVJB1yy7 #mededmooc

Patients do better if they know their results.

2011-12-01T16:06:00.001Z

A meta-analysis of anticoagulation studies by researchers from Oxford say that self-management is safe and can improve the quality of care.

"Patients who monitor their own treatment with warfarin or other blood-thinning drugs reduce their risk of developing blood clots by half, an Oxford University study has found. ...Taking charge of their own treatment can empower patients, improve the quality of treatment and be more convenient. The researchers say their findings confirm that self-monitoring of warfarin is safe for suitable patients of all ages." http://www.ox.ac.uk/media/news_stories/2011/110112.html

"Our [meta] analysis showed that self-monitoring and self-management of oral coagulation is a safe option for suitable patients of all ages. Patients should also be offered the option to self-manage their disease with suitable health-care support as back-up." http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61294-4/abstract

I note the recent JAMA editorial advising caution about a proposed rule to allow access to investigations by patients,

"The current policy of allowing state laws to limit patient access to test results could deter patient engagement, thereby contradicting the intention of transparency in health care reform. However, offering patients direct and potentially immediate access to laboratory results has potential consequences that must be addressed. Without involvement of physicians, delivery of abnormal test results will be a major concern. For example, patients having access to abnormal test results before physicians have had the opportunity to interpret and counsel patients may create unnecessary anxiety." http://jama.ama-assn.org/content/early/2011/11/22/jama.2011.1797.full

OK so anticoagulation monitoring is not the same as diagnostic interventions but it makes sense to assume that the person most likely to act quickly and efficiently on their results is the patient - the one with the most to gain. Access to results may generate 'extra' work for staff when patients prompt them into action (or reassurance) but isn't that work which would be done anyhow? It might change the scheduling of work and might just stimulate a more efficient system.

Open engagement with medical meetings

2011-11-30T17:00:00.001Z

Brian McGowan and Jennifer Smith make the case for accelerating the transfer of new ideas from medial meetings into clinical practice by having open discussions around the meetings between researchers, educators and clinicians.

They list the current methods of information flow from medical meetings highlighting the weaknesses that exist. They propose change to how data is curated after a medical meeting, how societies/associations can engage more openly by hosting 'clearing houses' for data, how investigators should defend their work and explore further research questions with the medical community, how technology should be used to break down knowledge silos, and how local education providers need to feedback to the clearing houses about the dissemination of the new data.

"Some may object to the re-engineering. Some may contest the change in the status quo. But this cannot be about business interests, copyright, or membership value propositions—three challenges that are valid, but can be practically and intelligently addressed though parallel innovation. This re-engineering is first and foremost about improving the flow of medical information."

Re-engineering the Data Stream from Meetings to Medical Practices. Cover story of current issue of Medical Meetings.

This medical society / association led, open publishing model would broaden access to new research findings and perhaps accelerate their transfer to clinical practice. It touches on the Digital Scholarship that Martin Weller has been discussing recently, and, in particular, the reward and tenure that academics work towards and the inevitable comment about open publishing - Yeah, but who pays?

However, as they point out ... not without its challenges.

#MedEdMOOC transcript 29/11/11

2011-11-29T15:27:00.001Z

Meeting of 29th November 2011

Agenda

After starting in Twitter with the #mededmooc tag we propose to move the meeting to Google+ video chat room to continue with video/voice chat.
Team formation: Why are you interested in doing a MOOC?
How will we make decisions? Basic decision making agreement and rules.
Next steps

See the Google Doc for a full description of MedEdMOOC

A few themes came out of the discussions of the 28th November and today.

The Siemens, Downes and Cormier style MOOC was organised by a small well-established team. This would not be possible with this MOOC which would probably be organised by a more diffuse, international team of multidisciplinary professionals in healthcare and education. This organising group would need to make some key decisions by consensus such as mission, dates, platforms, and syllabus.
The MOOC should be multidisciplinary as this would provide greater involvement and relevance. It would mean a focus on common challenges in healthcare rather than specialty-specific topics.
Personal learning about technologies, educational principles, research, applications of MOOCs and networking were key motivators for contributors those involved.

Tue, 29 Nov 2011 15:11:37 +0000 @dean_jenkins Great #MedEdMOOC hangout @BrianSMcGowan @RyanMadanickMD @MedPubDirector
Tue, 29 Nov 2011 15:06:37 +0000 @BrianSMcGowan "Topic Template: 1) title 2) problem statement 3) possible sources for solution or exploration #mededMOOC > these become our weekly topic"
Tue, 29 Nov 2011 15:05:44 +0000 @dean_jenkins Suggested topic template - title, gap / barrier statement with reference, what would happen, learning outcomes etc. #mededmooc
Tue, 29 Nov 2011 14:59:27 +0000 @BrianSMcGowan "To define the shared praxis for the #mededMOOC - r we engaging educators to use tech in teaching; or docs to use tech in practice?"
Tue, 29 Nov 2011 14:58:48 +0000 @MedPubDirector #mededmooc need to really determine what the goals of the participants and the goals of the organisers are
Tue, 29 Nov 2011 14:50:50 +0000 @MedPubDirector Just had an impromptu visit from my 2-yr old Amelia #mededmooc
Tue, 29 Nov 2011 14:48:42 +0000 @MedPubDirector #mededmooc get things shored up by the 20th Jan 2012 at the latest?
Tue, 29 Nov 2011 14:45:21 +0000 @MedPubDirector #mededmooc process measures and outcome measures key to evaluating impacts
Tue, 29 Nov 2011 14:44:08 +0000 @dean_jenkins Lets document our 'needs assessment' process in #MedEdMOOC to explain what we did when the MOOC's complete for presentation. @BrianSMcGowan
Tue, 29 Nov 2011 14:42:33 +0000 @dean_jenkins CME accreditation is desirable but not essential for #MedEdMOOC - different countries have different systems.
Tue, 29 Nov 2011 14:40:51 +0000 @MedPubDirector a carefully planned #mededmooc with obectives and assessment and portfolio narrative would be first of its kind
Tue, 29 Nov 2011 14:38:33 +0000 @MedPubDirector @deanjenkins CPD/CME accreditation more important for UK/US Drs thanperhaps other regions #mededmooc
Tue, 29 Nov 2011 14:38:24 +0000 @BrianSMcGowan 1) create a template for topic suggestions 2) crowdsource the priorities (rank) 3) schedule the topics effectively over 6wks #mededmooc
Tue, 29 Nov 2011 14:36:01 +0000 @BrianSMcGowan We will likely have the greatest impact on #meded by disrupting the parts of education that are often missed thru common channels #mededMOOC
Tue, 29 Nov 2011 14:35:27 +0000 @MedPubDirector #mededmooc suggesting a week for tweeps to review shared doc and feedback and then we move forward
Tue, 29 Nov 2011 14:30:41 +0000 @dean_jenkins Hanging out with @BrianSMcGowan @RyanMadanickMD and @MedPubDirector on #MedEdMOOC http://t.co/P3FNv9Jy
Tue, 29 Nov 2011 14:29:51 +0000 @BrianSMcGowan first come, first serve - playground mechanics? RT @MedPubDirector: interesting conversation paternlistic vs democratic #mededmooc
Tue, 29 Nov 2011 14:29:36 +0000 @MedPubDirector #mededmooc need a sub group to co-ordinate research activity and aims
Tue, 29 Nov 2011 14:23:49 +0000 @MedPubDirector interesting conversation paternlistic vs democratic #mededmooc
Tue, 29 Nov 2011 14:20:46 +0000 @BrianSMcGowan #mededmooc - should be multidisciplinary...governance is still a work in progress...we still need to call on expertise of adult educators.
Tue, 29 Nov 2011 14:18:25 +0000 @MedPubDirector Have fallen in love with #G+ #mededmooc
Tue, 29 Nov 2011 14:05:39 +0000 @dean_jenkins @amcunningham G+ Hangout http://t.co/P3FNv9Jy for #MedEdMOOC chat http://t.co/is6rCtnm
Tue, 29 Nov 2011 14:04:07 +0000 @BrianSMcGowan we are here now! RT @amcunningham: @dean_jenkins #mededmooc how are we starting?
Tue, 29 Nov 2011 14:03:34 +0000 @@dean_jenkins #mededmooc how are we starting?
Tue, 29 Nov 2011 13:59:30 +0000 @BrianSMcGowan #mededMOOC - time for us to continue the discussion. glad to be able to join today.
Tue, 29 Nov 2011 13:55:31 +0000 @dean_jenkins #MedEdMOOC chat http://t.co/is6rCtnm @bronwynah @grahambasten @dsdarbyshire @medpubdirector @MedEdHelen
Tue, 29 Nov 2011 13:55:09 +0000 @dean_jenkins #MedEdMOOC chat http://t.co/is6rCtnm @bronwynah @salt_mine @helen_otuk @lewismal @virtualot @brownleader
Tue, 29 Nov 2011 13:52:44 +0000 @dean_jenkins #MedEdMOOC chat http://t.co/is6rCtnm @meducate @claireOT @sarahstewart @MedPedsDoctor @bronwynah
Tue, 29 Nov 2011 13:46:22 +0000 @dean_jenkins "@MedPubDirector yes unless there are > 10 people ... will get one started. http://t.co/P3FNv9Jy for #MedEdMOOC chat http://t.co/is6rCtnm"
Tue, 29 Nov 2011 13:43:56 +0000 @dean_jenkins #MedEdMOOC chat http://t.co/is6rCtnm @amcunningham @nlafferty @BrianSMcGowan @RyanMadanickMD @ohsuneuro
Tue, 29 Nov 2011 13:42:41 +0000 @MedPubDirector Are we going to go to #G+ again? #mededmooc
Tue, 29 Nov 2011 13:41:02 +0000 @dean_jenkins "Meeting in 20 minutes on Twitter using the #MedEdMOOC hashtag. agenda -> http://t.co/is6rCtnm 28/11 meeting notes http://t.co/EO4eqmmm"
Tue, 29 Nov 2011 13:35:40 +0000 @MedPubDirector Looking forward to taking part in debate today in the safety of my study rather than on a train #mededmooc #meded
Tue, 29 Nov 2011 12:14:05 +0000 @dean_jenkins "@BrianSMcGowan Yes that's right #MedEdMOOC at 09:00 EST today. http://t.co/UeKQUj1j Hope you can make it. Probably Twitter -> G+ hangout"
Tue, 29 Nov 2011 12:10:52 +0000 @BrianSMcGowan @dean_jenkins - that is 9AM my time? (i hope) #MedEdMOOC
Tue, 29 Nov 2011 11:30:44 +0000 @dean_jenkins @drgandalf52 boo ... we'll volunteer you for something really challenging then. :-) #MedEdMOOC
Tue, 29 Nov 2011 10:27:19 +0000 @dean_jenkins Looking forward to #MedEdMOOC meeting today at 14:00 GMT. http://t.co/is6rCtnm Join us. Please RT.
Tue, 29 Nov 2011 09:55:02 +0000 @MedPubDirector Just commented on some of the points in the #mededmooc marketing plan would welcome feedback

Using shared patients to define networks of doctors.

2011-11-15T21:36:00.001Z

Open Medicine article from Ottawa where they examined administrative data of doctors to see how they were "interconnected". An interconnection was defined as "if these 2 physicians provided at least 1% of their clinic visits over a 2-year period to the same patients".

"Physicians had, on average, 2.2 interconnected physician partners (median = 1; 25th and 75th percentile: 0, 3). Physicians saw mainly their own listed patients, and 7.9% (median = 5.9%; 25th and 75th percentile: 2.4%, 11.6%) of their visits were provided to patients of their interconnected partners. The number of interconnected physicians was higher in group practices that had more physicians, but levelled to 2.5 interconnected physicians in practices with 8 or 9 physicians."

This was very much a 'proof-of-concept' study but the authors go on to suggest two possible uses of such techniques; the examination of collaborative healthcare centred on individual patients using social network techniques, and the examination of health care delivery from a network perspective.

1. Manuel DG, Lam K, Maaten S, Klein-Geltink J. Using administrative data to measure the extent to which practitioners work together: “interconnected” care is common in a large cohort of family physicians. Open Medicine 2011 Oct;5(4):177-182. Available from: http://www.openmedicine.ca/article/viewArticle/448

Research questions for dabigatran

2011-11-15T11:33:00.001Z

Had a *cough* free sandwich from the Boerhinger rep at the Friday lunchtime meeting last week in Truro where some slides were presented on dabigatran (Pradaxa).

I've been using scoop.it to pull together a number of recent articles on dabigatran and await the final determination of NICE which is due in December.

http://www.scoop.it/t/dabigatran

There are some research questions for dabigatran in AF.

How best to encourage compliance? With warfarin the intensity of the monitoring and the importance placed on it by healthcare staff surely encourages compliance. With the twice daily dosing of dabigatran and the absence of monitoring it will not be as good.
Is there a higher risk of MI or acute coronary syndrome? This was reported in a meta-analysis for the AHA this year.
How does dabigatran compare with the other new anticoagulants? e.g. rivaroxaban

Fruit, nuts and diabetes

2011-11-14T12:38:00.001Z

Well it seems that eating almonds at mealtimes may help reduce glucose excursions in the short term and improve glycaemic control in the long term [1]. Good news if you have diabetes and like nuts.

However, the picture is more complex for bananas. Apparently there are different species of banana but they all have a reassuringly favourable glycaemic index of about 60 - 70 [2]. The best bananas are, of course, Fairtrade bananas.

1. Cohen AE, Johnston CS. Almond ingestion at mealtime reduces postprandial glycemia and chronic ingestion reduces hemoglobin A(1c) in individuals with well-controlled type 2 diabetes mellitus. Metab. Clin. Exp. 2011 Sep;60(9):1312-1317. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21489570

2. Hettiaratchi UPK, Ekanayake S, Welihinda J. Chemical compositions and glycemic responses to banana varieties. Int J Food Sci Nutr 2011 Jun;62(4):307-309. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21250902

#MedEdMOOC meeting transcript

2011-11-07T23:35:00.006Z

Here is the transcript from this evening's Twitter chat about MedEdMOOC

Agenda

Introductions
T1 reality check
T2 Audit of available resources
T3 Proposed governance structure (membership, decision making, roles etc.)
T4 Aims / Interdisciplinary? / Mission / Naming of the MedEdMOOC voting
T5 Timescale
T6 Credits (CME / University / other)
T7 Draft syllabus and invited experts
T8 Next steps

From User	Tweet
claireOT	@dean_jenkins Thanks for organising the chat. I feel progress has been made! #mededmooc
dean_jenkins	@BrianSMcGowan you've worked your computer too hard these past few months clearly. :-) #mededmooc
BrianSMcGowan	@dean_jenkins ..sorry I missed #mededmooc ...had an IT disaster today and just returned from dropping off my computer for service...
claireOT	Anyone wanting to work on the MOOC for CPD in #MedEdMooc syllabus? I need 3 volunteers! sign yourselves up here http://t.co/PmKvKCNU
dean_jenkins	@BrianSMcGowan how do you so quickly curate #CMEchat for your blog? Would like to do the same with #MedEdMOOC
claireOT	RT @Helen_otuk: Great start folks! Thanks RT @dean_jenkins: Thanks all. Sorry to have run over time. Great chat. Will take time to digest. #MedEdMOOC
nlafferty	@dean_jenkins Thanks for organising #mededmooc chat tonight!
DairyGoodness	RT Know how u feel hav'g same so sending luck @lewismal Thx all. Feeling exhausted after my dental work.Good chat.Good progress #mededmooc
grahambasten	RT @amcunningham: @dean_jenkins thanks- agree very good start:) tweetchat worked better than i expected:) #mededmooc
claireOT	@dean_jenkins would you circulate an email pls? I'm happy to collaborate with anyone. Would like a group of 4, so need 3 more #mededMOOC
dean_jenkins	Thanks and goodnight. Great parallel work on the document http://bit.ly/MedEdMOOC #mededmooc
isa_mutlib	With the growing number of social networking users, I believe it's a good idea. However, privacy would be an issue in my opinion #mededmooc
drgandalf52	catch you all on the flipside #mededmooc
amcunningham	@dean_jenkins thanks- agree very good start:) tweetchat worked better than i expected:) #mededmooc
grahambasten	#mededmooc thanks all
dean_jenkins	I could set up a teleconference. Not sure of the maximum that could be online. Most countries would have local numbers. #mededmooc
Helen_otuk	Great start folks! Thanks RT @dean_jenkins: Thanks all. Sorry to have run over time. Great chat. Will take time to digest. #MedEdMOOC
bronwynah	@dean_jenkins thanks for the chat! #mededmooc
amcunningham	@grahambasten @lewismal bb collab used to be eluminate and works pretty well:) #mededmooc
lewismal	Thanks all. Feeling exhausted after my dental work. Good chat. Good progress #mededmooc
claireOT	@dean_jenkins sounds good #mededMOOC @amcunningham
grahambasten	@amcunningham @lewismal #mededmooc if bb col is better than actual bb?
dean_jenkins	Thanks all. Sorry to have run over time. Great chat. Will take time to digest. #mededmooc
lewismal	RTYES @amcunningham: @grahambasten @lewismal good idea... maybe even trial run of BB collaborate? #mededmooc
grahambasten	T8 #mededmooc happy to discuss further with teams at #dmu and report back
Helen_otuk	sounds goodRT @dean_jenkins: T8 - so another twitter chat (easy) and a voice meeting with @amcunningham s newly found BB collab? #MedEdMOOC
bronwynah	@lewismal I suspect things operate a little bit differently in massive but might be wrong ... esp across timezones #mededmooc #fluid team
dean_jenkins	tagged with? RT @claireOT: Ill develop a GDoc looking at the evidencing our MOOC for CPD, anyone want to join me? #mededmooc
dsdarbyshire	#mededmooc I think #moocmooc is a reasonable acronym for the course aims
theCMEguy	T6- CME certification can add an air of authenticity/legitimacy to an Ed activity. It does take a bit of effort tho... #mededmooc
Helen_otuk	@claireOT I would but that could be to OT! #MedEdMOOC
amcunningham	@grahambasten @lewismal good idea... maybe even trial run of BB collaborate? #mededmooc
dean_jenkins	T8 - so another twitter chat (easy) and a voice meeting with @amcunningham 's newly found BB collab? #mededmooc
lewismal	T8 We are in team formation stage-voice is helpful. #mededmooc
bronwynah	@lewismal not practicable nor sustainable for me unless directly in my course or part of my research agenda #mededmooc I am limited,
claireOT	@dean_jenkins I'll develop a GDoc looking at the evidencing our MOOC for CPD, anyone want to join me? #MedEdMOOC
grahambasten	Like RT @lewismal DO we need to work towards a voice VOIP meeting to discuss blurb & understand why we each of r are doing this? #mededmooc
Helen_otuk	AgreeRT @lewismal: DO we need to work towards a voice VOIP meeting to discuss blurb & understand why we each of r are doing this? #MedEdMOOC
grahambasten	RT @drgandalf52: another twitter meeting in a couple weeks, with some chats inbetween to update on the prev mentioned aspects #mededmooc
lewismal	DO we need to work towards a voice VOIP meeting to discuss blurb & understand why we each of r are doing this? #mededmooc
bronwynah	@dean_jenkins @amcunningham it's another type eg required engagement & participation I can build into my course requirements IRL #mededmooc
grahambasten	@amcunningham @dean_jenkins #mededmooc I know the feeling!
drgandalf52	another twitter meeting in a couple weeks, with some chats inbetween to update on the prev mentioned aspects #mededmooc
dean_jenkins	T8 Perhaps someone who is used to doing these things can curate the conversation and blog it somewhere or stick it in the doc. #mededmooc
dean_jenkins	T8 - Any suggestions for next steps? #mededmooc
dean_jenkins	@amcunningham but you're a #meded rock star now! #mededmooc
dean_jenkins	Bravo RT @lewismal: We could put up concept blurb and crowdsource suggestions for presentations/topics. #mededmooc
amcunningham	@grahambasten @dean_jenkins I"ve been tweeting and blogging for years to learn without accreditation :) #mededmooc
grahambasten	RT @lewismal We could put up concept blurb and crowdsource suggestions for presentations/topics. #mededmooc
Helen_otuk	like it RT @lewismal: We could put up concept blurb and crowdsource suggestions for presentations/topics. #MedEdMOOC
drgandalf52	practical implications of tech/social media to primary care #mededmooc
claireOT	RT @lewismal: We could put up concept blurb and crowdsource suggestions for presentations/topics. #mededmooc
nlafferty	@amcunningham I agree, don't think this should be our primary focus @deanjenkins #mededmooc more important things to get on with
lewismal	We could put up concept blurb and crowdsource suggestions for presentations/topics. #mededmooc
grahambasten	@amcunningham @dean_jenkins #mededmooc totally agree
dean_jenkins	RT @claireOT: learning how to evidence the process of MOOC towards our prof dev. is a good sub-topic. Happy to contribute to this #mededmooc
amcunningham	@grahambasten @dean_jenkins can on;y really be a resource for personal development to me... new models:) #mededmooc
claireOT	RT @dean_jenkins: w00t! RT @amcunningham: someone very nice has suggested they might have a BB Collaborate account we might be able to use:) #win #mededmooc
dean_jenkins	T7 - assuming we know roughly what our target audience is and wants. #mededmooc
claireOT	learning how to evidence the process of MOOC towards our prof dev. is a good sub-topic for #mededmooc. I'm happy to contribute to this
dean_jenkins	T7 - any suggestions for draft syllabus and invited experts? #mededmooc
amcunningham	@dean_jenkins yes, but I fear that the effort in establishing the sideshow might distract from more important activities... #mededmooc
dean_jenkins	w00t! RT @amcunningham: someone very nice has suggested they might have a BB Collaborate account we might be able to use:) #win #mededmooc
lewismal	T6 formal credits may be a lot of work by organizers for small gain in attendees. #mededmooc
dean_jenkins	T7 coming up then T8 and we finish! #mededmooc
amcunningham	#mededmooc someone very nice has suggested they might have a BB Collaborate account we might be able to use:) #win
claireOT	I amended the GDoc- check out the link to @SarahStewart 's model for possible combiation of open access/ masters credits #mededmooc
dean_jenkins	@amcunningham CK09 had credits - it's only a small side show really. #mededmooc
grahambasten	@amcunningham @dean_jenkins #prejudice #mededmooc I agree so needs focus, tension between an open resource for personal dev or a product £
drgandalf52	I think some form of cert ideal but not necessarily CME or others, we all like badges to show our appraisers but not essential #mededmooc
dean_jenkins	#mededmooc @dsdarbyshire Here's the blurb about CME accreditation from BMJ Learning. http://t.co/VKeLIsgy ?
claireOT	RT @amcunningham: @dean_jenkins hmmm I think that people doing this for a university credit may have wrong expectation of a MOOC #prejudice #mededmooc
amcunningham	@grahambasten @dean_jenkins nope this is all new to me but I love learning:) #mededmooc
amcunningham	@dean_jenkins hmmm I think that people doing this for a university credit may have wrong expectation of a MOOC #prejudice #mededmooc
grahambasten	@dean_jenkins @amcunningham #mededmooc like lbr learning beyond registration etc?
ohsuneuro	I like #MedEdMOOC (I'll vote later). For aims, is this about all tech or just SoMe? (sorry can't stay for response - between pts).
dean_jenkins	@dsdarbyshire BMJ learning uses EPASS among other things. #mededmooc
Helen_otuk	Not important to all... but good for those who are interested. #MedEdMOOC
lewismal	meant to say -T6. These are helpful but NOT essential #mededmooc
dean_jenkins	@amcunningham but university credits can be very attractive to some. #mededmooc
dsdarbyshire	#mededmooc what is the process for bmj learning modules being accredited? Relevant?
APSQLD	@lewismal wow you talk alot #mededmooc
grahambasten	@dean_jenkins #mededmooc will look at uni credits
lewismal	T6. These are helpful but essential. Adds credibility for all. If after all else is done, I see benefits of applying for these. #mededmooc
claireOT	@dean_jenkins oooh, can I put it towards my Master's? great!! #mededmooc
Helen_otuk	I know that some OT education peeps have been doing some exploration. But maybe not for first try??? I do not know, #MedEdMOOC
grahambasten	RT @dean_jenkins: T6 - CME / CPD credits and University credits (Masters Level). Any suggestions? #mededmooc
dean_jenkins	T6 - I'm working with a friendly UK University already and will explore Masters level credits. #mededmooc
amcunningham	@dean_jenkins #mededmooc I think university credits are a distraction... participation should have own rewards...
grahambasten	@amcunningham #mededmooc small tasters and examples of best practice off the shelf
dean_jenkins	T6 - Some US colleagues are already looking at CME points (for medics). Think this is great. #mededmooc
dean_jenkins	T6 - CME / CPD credits and University credits (Masters Level). Any suggestions? #mededmooc
Helen_otuk	Agree: While core member needs to be mindful of their calenders, be mindful moocs are global, local calendars not that important. #MedEdMOOC
lewismal	While core member needs to be mindful of their calenders, be mindful moocs are global, local calendars not that important. #mededmooc
amcunningham	@grahambasten brown bag sessions soft launch??? needs explanation for me:) #mededmooc
grahambasten	#mededmooc t5 prob may 2012 although brown bag sessions soft launch sooner?
drgandalf52	if April can we do AFTER the hols, just aware GP land goes mental then.....#mededmooc
dean_jenkins	T6 coming up ... will finish quickly as going to run over the hour now. #mededmooc
lewismal	T5 Until we do poject plan draft we cannot estimate timeline well. #mededmooc
dean_jenkins	T5 - the average suggestion seems to be April. I think that is realistic. #mededmooc
claireOT	I've set out a definition for you all to pick apart- easier once something is down! #mededmooc
amcunningham	@bronwynah @claireOT @dean_jenkins agree!!!!!! #mededmooc
lewismal	I have a longed planned long service leave holiday camping in remote Aust over December & Jan . Latter in year works 4 me. #mededmooc
dean_jenkins	@marymodahl Have a look at http://t.co/is6rCtnm for the planning document. #mededmooc
dean_jenkins	@nlafferty agree I think #MedEd is OK ... @claireOT work on the 50-word explanation! #mededmooc
marymodahl	#mededmooc what is this about? Just happened on this hashtag and see debate about the name but not sure what the group is?
nlafferty	@claireOT #meded chat gets participation from across the health professions quite successfully , doesn't seem to put people off #mededmooc
myihateapp	@dean_jenkins I think we're looking at April/May soonest, realistically #MedEdMOOC #MyiHateApp
lewismal	T5 new mooc should not start until a decent break after #change11 #mededmooc
amcunningham	@claireot @Helen_otuk @dean_jenkins I like Manymoon but only one free project each so someone else needs to 'own' this one:) #mededmooc
claireOT	@dean_jenkins I think we're looking at April/May soonest, realistically #MedEdMOOC
drgandalf52	march #mededmooc
claireOT	RT @lewismal: Agreeing on a 50 word explanation is the real big agreement we need to make. #mededmooc
dean_jenkins	T5 - when should the yet-to-be-named-MOOC run? #mededmooc
claireOT	@amcunningham I'm interested to try that out. I have never played with ManyMoon #mededMOOC @dean_jenkins
lewismal	RT YES @dsdarbyshire: #mededmooc I think once a clear aim is devised a name will appear, not the other way. #mededmooc
dean_jenkins	@lewismal 50 word explanation challenge is open on http://bit.ly/MedEdMOOC #mededmooc
Helen_otuk	@amcunningham oh new tool... not used that before ManyMoon... #MedEdMOOC
dean_jenkins	@amcunningham sounds good - would like to learn #mededmooc
lewismal	Agreeing on a 50 word explanation is the real big agreement we need to make. #mededmooc
dean_jenkins	OK put all possible names in the planning document. Feel free to make new sections. T5 coming up. #mededmooc
amcunningham	@dean_jenkins we could use ManyMoon to project manage... integrates really well with google docs:) #mededmooc
Helen_otuk	RT @dsdarbyshire: #mededmooc I think once a clear aim is devised a name will appear, not the other way. #MedEdMOOC
dsdarbyshire	#mededmooc I think once a clear aim is devised a name will appear, not the other way.
amcunningham	@claireOT @lewismal @deanjenkins if google form then all results within google docs... #mededmooc
lewismal	The hashtag and name and short blurb is a part of the marketing plan. Do it as part of that. Until then live with working title. #mededmooc
claireOT	@dean_jenkins great minds think alike ;-) surveymonkey! #mededmooc @amcunningham @lewismal
dsdarbyshire	#mededmooc acadmeded had same discussion before agreeing a name.
grahambasten	Yep RT @dean_jenkins T4 - can we put all the name suggestions into the document http://t.co/QBGAcDIy and we vote on it? #mededmooc
dean_jenkins	@claireOT http://t.co/h9T24Xr7 #mededmooc
claireOT	@nlafferty I think #MedEdMOOC could turn off the non-medics... but it depends what the group decides, I could be wrong!
kenny_cox	Agreed @lewismal: We need to work out what hashtag connects with our intended market. #mededmooc
drgandalf52	hmmm med too narrow, healthmooc excludes tech...how about healthtechmooc or shorter HTechMooc ? #mededmooc which doesnt identify the tech.
lewismal	We need to work out what hashtag connects with our intended market. #mededmooc
dean_jenkins	T4 - can we put all the name suggestions into the document http://t.co/is6rCtnm and we vote on it? #mededmooc
amcunningham	@dean_jenkins @kenny_cox think we need to drop mooc for title ... 4 characters reclaimed! #mededmooc
claireOT	@amcunningham @lewismal Survey Monkey? #MedEdMOOC
dean_jenkins	surveymonkey! RT @amcunningham: @lewismal yes, we need a google doc on name alone and way to vote:) a google form! #mededmooc
nlafferty	@claireOT Think #mededMOOC is understandable - people will know what it's about, other suggestions to vague?
Helen_otuk	RT @amcunningham: @lewismal yes, we need a google doc on name alone and way to vote:) a google form! #MedEdMOOC
dean_jenkins	Sounds good. RT @kenny_cox: HealthMOOC seems extremely broad - Maybe HCPTechMOOC? #mededmooc
Helen_otuk	RT @claireOT: #HealthTechMOOC? too long, perhaps... #MedEdMOOC
amcunningham	@lewismal yes, we need a google doc on name alone and way to vote:) a google form! #mededmooc
grahambasten	@amcunningham @Helen_otuk #mededmooc hed could be higher education and hcp could be our new DoH MSC healthcare science programme?
lewismal	@amcunningham Yes audience people working in health is target group #mededmooc
claireOT	Can we collate a few options and run a poll on the GDoc for the final name, then we can move on to the next q... #MedEdMOOC
kenny_cox	HealthMOOC seems extremely broad - Maybe HCPTechMOOC? #mededmooc
Helen_otuk	@amcunningham think audience should be both! #MedEdMOOC
claireOT	#HealthTechMOOC? too long, perhaps... #MedEdMOOC
lewismal	We may need to involve target group in name selection. #mededmooc
Helen_otuk	RT @claireOT: @drgandalf52 I prefer #HealthMOOC- I dont define my practice by the medical model ;-) #MedEdMOOC
amcunningham	@lewismal you mean audience should be practitioners rather than educators? my focus is on learning btw #mededmooc
Helen_otuk	@amcunningham true... #MedEdMOOC
nlafferty	@dean_jenkins Does healthMOOC convey what if's really about #mededmooc
lewismal	@drgandalf52 Tech suggests it will be about the tech not the change as in #change11 To narrow #mededmooc
claireOT	@drgandalf52 I prefer #HealthMOOC- I don't define my practice by the medical model ;-) #MedEdMOOC
grahambasten	@dean_jenkins #mededmooc ah the old name game as Wogan would say for me any medical/health/tech in name is fine
amcunningham	@Helen_otuk I liked HEd... but would people think highered? same difference ? ;) #mededmooc
dean_jenkins	Hello @kenny_cox so what name do you suggest? :-) #mededmooc
drgandalf52	how about medtechMooc ? #mededmooc
lewismal	Keep the focus on learning not education- why #meded is not right. Also suggest pre-service education only #mededmooc
dean_jenkins	T4 - prefer HealthMOOC to HCPMOOC #mededmooc
amcunningham	RT @dean_jenkins: T4 - hurrah! We have disagreement at last (on naming). This is progress. #mededmooc
amcunningham	@claireOT HCP as in health care practitioner... not health care preactitioner education? #mededmooc
kenny_cox	#mededmooc Have been lurking and am very curious - Aims are spot on - Tech in hash tag makes sense when aims are considered
Helen_otuk	#HEd12MOOC #MedEdMOOC
dean_jenkins	T4 - hurrah! We have disagreement at last (on naming). This is progress. #mededmooc
drgandalf52	id think something more tech sounding needed in the hastag.... #mededmooc
amcunningham	@grahambasten yes, I agree that issues more likely to be trans rather than interdisciplinary... makes sense to widen ++ #mededmooc
lewismal	T4 I suggest HealthMooc 0r #H12mooc- Meded is not right #mededmooc
bronwynah	@dean_jenkins moi aussi #mededmooc interdisciplinary collaborative overlapping area / multiple modalities loose design for participant lead
dean_jenkins	RT @Helen_otuk: @grahambasten agree, would fit with how MOOCs go... big group weekly topic some big group smaller sets within #mededmooc
claireOT	How do you guys feel about #HCPMOOC? I feel it emphasises inter-professional focus. Once we've done that, we could spin out #MedEdMOOC
Helen_otuk	Not agree... RT @dean_jenkins: T4 - so is MedEd the right prefix? (I think it is). #MedEdMOOC
Helen_otuk	@grahambasten agree, that would fit with how MOOCs tend to go... big group weekly topic some big group and smaller sets within #MedEdMOOC
dean_jenkins	T4 - so is MedEd the right prefix? (I think it is). #mededmooc
amcunningham	@Helen_otuk @dean_jenkins @lewismal well about half people or more to turn up to this meeting are not docs at least! #mededmooc
lewismal	T4 I vote interdisciplinary, transdisciplinary #mededmooc
grahambasten	Yep to this RT @lewismal @dean_jenkins Best done in google docs as a project plan not here and now. #mededmooc
dean_jenkins	Nice RT @drgandalf52: think must be interdisciplinary, mission, broaden knowledge and practices of tech in practice maybe? #mededmooc
lewismal	Aims/audience seems to be key issue for many committing including me. #mededmooc
grahambasten	#mededmooc t4 clearly inter ( trans) would be good but with drop down silos as needed, given the merging of professions with msc/ESP ptp etc
drgandalf52	think must be interdisciplinary, mission, broaden knowledge and practices of tech in practice maybe? #mededmooc
dean_jenkins	T4 - I vote interdisciplinary. #mededmooc
Helen_otuk	RT @amcunningham: @dean_jenkins before tasks can we clarify aims/audience? #mededmooc @lewismal #MedEdMOOC
claireOT	RT @lewismal: For me key issue, must include ongoing professional learning and interdisciplinary across health, emphasis on learning #mededmooc
Helen_otuk	Hi Claire, great timing..just on that subject #MedEdMOOC
dean_jenkins	T4 - Please feel free to edit the aims in the document. http://t.co/is6rCtnm #mededmooc
lewismal	@dean_jenkins Best done in google docs as a project plan not here and now. #mededmooc
amcunningham	@dean_jenkins before tasks can we clarify aims/audience? #mededmooc @lewismal
claireOT	Hello all #MedEdMOOC, just caught up on the chat so far. I'm in, if there's an inter-professional focus to the work.
dean_jenkins	@bronwynah hello ... we were killing time till you came. #mededmooc
amcunningham	@rajeeva Hello! You presented just after me at #altc2001 :) Wondering if you could help us with #mededMOOC ? How best to get in contact?
dean_jenkins	@lewismal agree ... let's get the tasks defined then. #mededmooc
bronwynah	@dean_jenkins hello! #mededmooc Bronwyn speech path primary area communication and swallowing disability health related all populations
Helen_otuk	Agree RT @lewismal: Role/tasks arise out of what needs to happen. eg marketing, tech support, wiki set up, presenter liaison #MedEdMOOC
dean_jenkins	T4 - what are the overall aims? Is it interdisciplinary? What's the mission? What's the name? #mededmooc
lewismal	@dean_jenkins Role/tasks arise out of what needs to happen. eg marketing, tech support, wiki set up, presenter liaison #mededmooc
grahambasten	@dean_jenkins t3 #mededmooc document updated
dean_jenkins	T4 coming up ... trying to stick to time. #mededmooc
dean_jenkins	@nlafferty sure of course ... they seem very open to helping out #mededmooc
nlafferty	@dean_jenkins We could still touch base with them and see if they could give us some tips on organising a mooc #mededmooc
dean_jenkins	T3 @lewismal how to define roles / tasks? Self-selection? #mededmooc
drgandalf52	@Helen_otuk both but particularly participants, to allow inclusion #mededmooc
lewismal	If we can work out roles /tasks& give high autonomy to those doing these roles/tasks. it would help #mededmooc
dean_jenkins	bravo RT @nlafferty: #mededmooc I can give some time and accrued knowledge like @amcunningham #mededmooc
amcunningham	@dean_jenkins lol at your editing my tweet for rt'ing... will see what I can do... did you cost? #mededmooc
dean_jenkins	T2 - I can tidy up the document! http://t.co/is6rCtnm #mededmooc
dean_jenkins	T3 - could those who haven't added their names to the document do so? http://t.co/is6rCtnm #mededmooc
Helen_otuk	@drgandalf52 do you mean from the core organisers or the MOOC participants? #MedEdMOOC
drgandalf52	membership, outline expectations from members, and needs clear structure... #mededmooc
nlafferty	#mededmooc I can give some time and accrued knowledge like @amcunningham
dean_jenkins	w00t RT @amcunningham: @dean_jenkins Blackboard Collaborate were at #altc2011 just after me... free account for #mededmooc
lewismal	We need to use voice comms at time to reach agreement #mededmooc
amcunningham	@dean_jenkins Blackboard Collaborate were at #altc2011 just after me... maybe I could ask speaker to get us free account for #mededmooc? :)
drgandalf52	i can give time, my website if needed (though dont think specific to this) and maybe some ideas from a European call.... #mededmooc
dean_jenkins	T3 - we've touched on this already but any other suggestions for governance? #mededmooc
nlafferty	#mededmooc Think we should aim for 6 weeks - for our first attempt - agree with @drgangadalf 8 weeks too long
lewismal	If mooc focus only narrow 6 weeks fine, but if wider need more slots. #mededmooc
grahambasten	@dean_jenkins t2 #mededmooc examples of expertise also have a transdisciplinary group and potentially some money from sha to develop
dean_jenkins	Hate to rush but T3 coming up. #mededmooc
dean_jenkins	@MedPubDirector thanks talk to you again. #mededmooc
lewismal	I can give 6hrs per week plus facilitation skills #mededmooc
Helen_otuk	I can not make any representation from my organisation... but I will donate time and personal opinion OT perspective #MedEdMOOC
amcunningham	@drgandalf52 I agree 8w is long... 5 or 6 better #mededmooc
dean_jenkins	T2 - I can probably quite easily get some IT stuff from BMJ Group or fund it myself. #mededmooc
MedPubDirector	going to have to give up internet access down on the train but will catch up on this tomorrow #mededmooc
dean_jenkins	@amcunningham That's ideal! #mededmooc
dean_jenkins	@nlafferty I reckon they have a small organising group. They were here earlier ... should have asked. :-) #mededmooc
lewismal	@drgandalf52 Sponsorship from Universities assume is possible. #mededmooc
amcunningham	@dean_jenkins T2 only resource I have is hopefully some time and accrued knowledge/skills :) #mededmooc
dean_jenkins	T2 let me rephrase then. What could we bring personally and from our organisations without much difficulty? #mededmooc
lewismal	@dean_jenkins Best size depends on length of course. But say 8 weeks, core team of 6 plus guess presenters #mededmooc
nlafferty	@deanjenkins #mededmooc Would be interested to know how large planning group is on MOOCs run by @gsiemens and @downes
grahambasten	@dean_jenkins #mededmooc T2 third phase jisc bid for #oer & virtual path labs & http://t.co/N8ie6QS6 & http://t.co/cLr2cn7m
amcunningham	RT @lewismal: For me key issue, must include ongoing professional learning and interdisciplinary across health, emphasis on learning #mededmooc
dean_jenkins	T2 @ohsuneuro offered US CME support. #mededmooc
lewismal	For me key issue, must include ongoing professional learning and interdisciplinary across health, emphasis on learning #mededmooc
drgandalf52	@lewismal but who would be your sponsor? #mededmooc
Helen_otuk	AGREE! RT @amcunningham: I put a strong vote for interdisciplinary.... #mededmooc @dean_jenkins #MedEdMOOC
amcunningham	@Helen_otuk I put a strong vote for interdisciplinary.... #mededmooc @dean_jenkins
dean_jenkins	@lewismal What size is best do you think? #mededmooc
lewismal	T2 If we use sponsorship, we can get ITC resources we need & perhaps a secretary. #mededmooc
drgandalf52	dont see why just has to be medics, re resources, what do you mean, skills? tech? academics? #mededmooc
dean_jenkins	@Helen_otuk Hope to get into the disciplines discussion shortly I hope. #mededmooc
Helen_otuk	@dean_jenkins I would be interested in getting involved... but depends on scope? Interdisciplinary or medics only? #MedEdMOOC
dean_jenkins	@grahambasten we'll come onto that (which disciplines) shortly I hope #mededmooc
lewismal	We also need to headhunt for more in core group. Not to big, not to small. #mededmooc
dean_jenkins	T2 What resources do we have available among us? #mededmooc
grahambasten	@dean_jenkins #mededmooc good idea if we feel allied ed also has a place or you specific for medics?
lewismal	I would join a core group #mededmooc
amcunningham	@dean_jenkins that's fair enough #mededmooc
drgandalf52	are we missing anyone? RT @dean_jenkins: Could I suggest those in the document and here now are the core group? #mededmooc
amcunningham	@cephas80 more Cardiff mafia :) #mededmooc
Helen_otuk	if topics and design are good then people will find their own flow, beauty of a MOOC #MedEdMOOC
dean_jenkins	T2 from agenda coming up. #mededmooc
Moigriff	RT @amcunningham: @dean_jenkins #it's many things to many people- can certain;y work in many forms if people understand that:) #mededmooc
cephas80	#mededmooc intro: first5 GP locum, academic fellowship hopeful, MSc psychiatry yr 1 student Cardiff university
Helen_otuk	@lewismal this we need to decide... if a core group established then further work needed? #MedEdMOOC
amcunningham	@drgandalf52 @dean_jenkins yes, I think if plan is tight in some ways it allows people more freedom when they get into #mededmooc
dean_jenkins	T1 (is it a goer) but @lewismal MOOCs need to be planned by somebody to set the scene. #mededmooc
lewismal	@amcunningham Governance is about how do we coordinate and make decisions #mededmooc
dean_jenkins	Good point RT @lewismal: T1 How does a group of peeps make decisions together when they have not met and the topic is emergent #mededmooc
lewismal	T1 Hows does a group of peeps make decisions together when they have not met and the topic is emergent #mededmooc
amcunningham	@lewismal talk more about governance... is this usually important in a #mooc? #mededmooc
dean_jenkins	So we're getting a yes probably but if we can get a good plan together? #mededmooc
grahambasten	#mededmooc is key to msc sha agenda and relevant to all across med ed
nlafferty	#mededmooc think it can work but think we need to be careful not to be too ambitious with our first attempt
Helen_otuk	I think so... but structure and audience are issues? #MedEdMOOC
brainduck	Social media in medical education http://t.co/1ib0oaEu interesting discussion on now, follow #MedEdMOOC.
dean_jenkins	I think it can happen. It could be quite complex and multidisciplinary but hey that's great. #mededmooc
lewismal	T1. Its a goes if governance and human resources issues can be solved. Need enough committed people & a way to work together. #mededmooc
amcunningham	@dean_jenkins #it's many things to many people- can certain;y work in many forms if people understand that:) #mededmooc
drgandalf52	think it can work but needs to address a few issues, mainly aims and structure #mededmooc
dean_jenkins	@drgandalf52 Yep ... vote now :-) #mededmooc
dean_jenkins	Reality check. So? Is this a goer? #mededmooc
drgandalf52	@dean_jenkins the reality check? #mededmooc
amcunningham	@dean_jenkins think there are more than 10 of us so g+ out:) #mededmooc
dean_jenkins	Here's the agenda and planning document. http://t.co/is6rCtnm #mededmooc
dean_jenkins	First agenda item coming up (after the introductions) ... #mededmooc
brainduck	RT @dean_jenkins: #MedEdMOOC tweet chat in 25 minutes at 22:00 GMT. Agenda on http://t.co/is6rCtnm
grahambasten	#mededmooc Graham - deputy head: school of allied health at #dmu previously at med schools of Sheffield & Nottingham
MedPubDirector	Evening Matt Green here Publishing Director with a keen interest in online learning for medics #mededmooc .
APSQLD	@lewismal Hi malcolm hows t'bar today #mededmooc
nlafferty	#mededmooc Hello All - Natalie Lafferty, lecturer in elearning & elearning lead at Dundee Medical School, UK
amcunningham	I'm a GP and lecturer in Cardiff University #mededMOOC
Helen_otuk	Helen, OT in social care #MedEdMOOC
lewismal	I work in mental health promotion in a public health unit #mededmooc
lewismal	Morning all. Malcolm from Toowoomba Queensland Australia here. #mededmooc
dean_jenkins	Introductions? Dean Jenkins, Cornwall, Physician, works with BMJ Group mostly and at Royal Cornwall Hospital. #mededmooc
drgandalf52	im here,GP, academic teaching fellow in Yorkshire, First5 man,tech enthusiast and all round magical being, with the beard too.. #mededmooc
grahambasten	Hi #mededmooc
dean_jenkins	Hi @Helen_otuk #mededmooc
nlafferty	@dean_jenkins Hi I'm here too #mededmooc
lewismal	Had a molar extracted yesterday due to abyss, so let's see if my brain works thru painkllers. #mededmooc
amcunningham	@dean_jenkins i'm here #mededmooc
Helen_otuk	Good evening all #MedEdMOOC
dean_jenkins	So who is here then? #mededmooc
dean_jenkins	Hi @Helen_otuk #mededmooc
nlafferty	@dean_jenkins Hi I'm here too #mededmooc
lewismal	Had a molar extracted yesterday due to abyss, so let's see if my brain works thru painkllers. #mededmooc
amcunningham	@dean_jenkins i'm here #mededmooc
Helen_otuk	Good evening all #MedEdMOOC
dean_jenkins	So who is here then? #mededmooc
dean_jenkins	RT @lewismal: About 2 join an early planning meeting about #MedEdMOOC. agenda is on http://t.co/is6rCtnm #mededmooc
lewismal	About 2 join an early planning meeting about #MedEdMOOC. The document and agenda is on http://t.co/82hh4i8l #mededmooc #mededmooc
dean_jenkins	Try to retweet key points to your network and make (some) tweets (at least) whole thoughts! #mededmooc
dean_jenkins	Please remember to use the hashtag #mededmooc
dean_jenkins	All comments are assumed to be personal and not those of your organisation unless you say otherwise. #mededmooc
dean_jenkins	Hello and welcome to the planning meeting for #MedEdMOOC. The document and agenda is on http://t.co/is6rCtnm #mededmooc
dean_jenkins	@theCMEguy Thanks Derek! #mededmooc
theCMEguy	Can't make #MedEdMOOC chat today, but happy to help with AMA/ACCME certification if needed. Will check in later...
dean_jenkins	10 minutes to an early planning meeting about #MedEdMOOC. The document and agenda is on http://t.co/is6rCtnm #mededmooc
HallyMk1	@amcunningham -> RT @dean_jenkins: #MedEdMOOC tweet chat in 25 minutes at 22:00 GMT. Agenda on http://t.co/mpjNBoUx
dean_jenkins	@amcunningham We could move it to another platform once we say our hellos. Perhaps G+? #mededmooc
dean_jenkins	Thanks @gsiemens @davecormier - we'll see if it survives its first planning meeting. :-) #mededmooc
amcunningham	@davecormier @gsiemens ha! Think a tweetchat to plan is even more ambitious! #mededMOOC @dean_jenkins
gsiemens	@dean_jenkins @davecormier - looks good! I think it's great that you've started the #medEdMOOC. Look forward to following it!!
dean_jenkins	.@gsiemens @davecormier hope the "What is a MOOC?" section is up to scratch on http://t.co/is6rCtnm #MedEdMOOC #mededmooc
davecormier	@gsiemens what a fascinating discussion #mededmooc
gsiemens	nice RT @dean_jenkins: #MedEdMOOC tweet chat in 25 minutes at 22:00 GMT. Agenda on http://t.co/hklc9wnw
dean_jenkins	#MedEdMOOC tweet chat in 25 minutes at 22:00 GMT. Agenda on http://bit.ly/MedEdMOOC
Helen_otuk	RT @dean_jenkins: #MedEdMOOC tweet chat at 22:00 GMT today - draft agenda for editing at http://bit.ly/MedEdMOOC please RT
ohsuneuro	@dean_jenkins Of course, I promised them the #mededMOOC would be huge, so we need to make it HUGE. ;)
dean_jenkins	Game on! RT @ohsuneuro Absolutely! Nothing firm yet, but there's a good chance I can get funding for US CME from my institution. #MedEdMOOC
dean_jenkins	Redirect Notice: #MedEdMOOC tweet chat at 22:00 GMT today - draft agenda for editing at http://bit.ly/MedEdMOOC please RT http://t.co/gg51UY5d
amcunningham	RT @dean_jenkins: #MedEdMOOC tweet chat at 22:00 GMT today - draft agenda for editing at http://bit.ly/MedEdMOOC please RT
dean_jenkins	#MedEdMOOC tweet chat at 22:00 GMT today - draft agenda for editing at http://bit.ly/MedEdMOOC please RT

Bounded rationality, medicine and the internet age.

2011-11-07T09:07:00.010Z

Clinicians use simple heuristics (rules) to guide their judgement until they reach a 'saturation point'. They have 'bounded rationality' that means they are not entirely rational and this helps them cope with the complexity of their practice.

"‘Saturation point’ was defined as the moment when physicians decide to stop using heuristics. It could be reached either because physicians confirmed a hypothesis or because they halted the process until further discussion was held with peers or they could wait for further evolution of their patients' condition. This method of limiting and stopping the search as soon as they felt satisfied with the decision is part of Simon & Selteńs models of bounded rationality. As soon as the physician using hypothesis-specific heuristics with a positive test strategy found a pattern, the process was stopped and a diagnosis was reached. This process could be delayed when there were many cues to the diagnosis that needed to be refuted. The effort to refute cues lead to a reduction in physician's confidence and a rise in uncertainty levels. Contradictions from the environment, particularly contradicting peer opinion led to the same result. Confidence in own judgment is also found to be an important factor in decision making whereby employing heuristics. In our study, confidence was a chief factor for establishing the saturation point, but it certainly was not the only component. For instance, time pressure, although not observed in this study, must be taken into account, and further study should be conducted in this area." [1]

The authors go on to make suggestions for the construction of clinical practice guidelines.

Reading this made me think about what are the implications for the use of 'emerging technologies' in medicine. Apart from the 'early adopters' of technology these new digital tools of social media, ubiquitous web and the analysis of data from electronic health records, represent added complexity - not necessarily simpler healthcare.

Herbert Simon was rewarded for his work on the rational decision making in business organization with the Nobel Prize for economics in 1978. Has this concept of 'bounded rationality' - that individuals aren't as smart as they may think they are and develop simpler techniques and rules to survive in complex environments - helped the world of economics? Is it true that everybody knew what they were doing with complex financial derivatives that turned out to be toxic debt in the 2008 crash? Did anyone understand them? The problem was they took emerging technologies and created new simple business rules to maximise the benefit of the technologies but assuming there was little or predictable risk.

I wonder if we are sometimes also at risk of introducing new and simple rules for healthcare professionals to help convince them of the utility of emerging technologies.

If you all you have is a hammer then everything looks like a nail. (Maslow's Law of the Instrument). Also, if you are obsessed with an emerging technology then everything looks like it is amenable to it.

We need to help develop effective heuristics for engaging with emerging technologies that are of proven value for improving patient care.

1. Bonilauri Ferreira APR, Ferreira RF, Rajgor D, Shah J, Menezes A, Pietrobon R. Clinical reasoning in the real world is mediated by bounded rationality: implications for diagnostic clinical practice guidelines. PLoS ONE 2010;5(4):e10265. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20421920

Insulin for acute stroke - no benefit

2011-10-31T14:39:00.002Z

In acute stroke previous research has suggested that managing hyperglycaemia could limit neurological damage and improve outcomes. However, a recent Cochrane review suggests that there is no benefit.

"Evidence from this systematic review indicates that, compared with control intervention, the administration of insulin to maintain glucose within a specific range immediately after acute ischaemic stroke does not reduce dependency, neurological deficit or mortality at 30 days or 90 days. These findings did not change in the subgroup analysis of those with diabetes mellitus compared to those without diabetes mellitus. There was, however, a significant increase in episodes of hypoglycaemia in the treatment group. This review provides no evidence to support the use of intensive insulin therapy for tight glucose control after acute stroke." [1]

1. Bellolio MF, Gilmore RM, Stead LG. Insulin for glycaemic control in acute ischaemic stroke. Cochrane Database Syst Rev 2011;9:CD005346. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005346.pub3/full

Jury still out on 'pay for performance'

2011-10-31T14:25:00.003Z

Recent Cochrane review published on financial incentives and quality of healthcare in primary care [1] shows that the jury is still out. "there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation."

In the last couple of years some research published by Imperial College in London suggested there was some benefit for certain types of patients in diabetes. [2] [3]

Quality interventions are often multi-factorial. Although they may appear to have high face-validity but to be certain that particular aspects work as intended more careful study is required of how they change behaviour. The jury is still out on whether 'pay for performance' is beneficial.

1. Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, Young D. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011;9:CD008451. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008451.pub2/full

2. Alshamsan R, Millett C, Majeed A, Khunti K. Has pay for performance improved the management of diabetes in the United Kingdom? Prim Care Diabetes 2010 Jul;4(2):73-78. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20363200

3. Millett C, Bottle A, Ng A, Curcin V, Molokhia M, Saxena S, Majeed A. Pay for perfomance and the quality of diabetes management in individuals with and without co-morbid medical conditions. J R Soc Med 2009 Sep;102(9):369-377. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19734534

Foam dressings for diabetic foot ulcers - Cochrane Review

2011-10-31T14:13:00.002Z

Cochrane review of foam dressings for healing diabetic foot ulcers concludes:

"We found no evidence that foam dressings promote the healing of diabetic foot ulcer compared with basic wound contact dressings. When data from two studies (eight and 12 weeks follow-up) were pooled, there was no statistically significant difference in ulcer healing between alginate and foam dressings. Similarly there was no evidence of a difference in the number of diabetic foot ulcers healed between foam and hydrocolloid (matrix) dressings. We note that most included studies were evaluating treatments on participants with non-complex foot ulcers. This means the body of literature presented may be of limited use to health professional in the treatment of patients with harder to heal foot ulcers as it is difficult to generalise from the included studies to patients with more co-morbidities or complications; this is a limitation of the RCTs that have been undertaken in this field thus far. Included trials were small and therefore statistically underpowered to detect important treatment differences should they exist." [1]

No evidence of clinical benefit from foam dressings and generally poor quality studies. This is a good reminder that it is not often about what you "put on" the ulcer but what pressure you "take off".

1. Dumville JC, Deshpande S, O’Meara S, Speak K. Foam dressings for healing diabetic foot ulcers. Cochrane Database Syst Rev 2011;9:CD009111. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009111.pub2/full

Reminder of the poor outcomes for foot care in diabetes

2011-10-26T15:18:00.004+01:00

In this study - a prospective cohort of 291 patients managed to current evidence-based guidelines in French hospitals - the authors concluded:

"Most of the wounds were located on the toes and forefoot, and infection was most often graded as moderate; nevertheless, in about 50% of patients, osteomyelitis was suspected. Also, 87% of patients had peripheral neuropathy and 50-62% had peripheral artery disease. Gram-positive cocci, and Staphylococcus aureus in particular, were by far the most frequently isolated microorganisms. During hospitalization, lower-limb amputation was performed in 35% of patients; in 52%, the wound healed or had a favourable outcome. A year after discharge, 150 non-amputated patients were examined: at this time, 19% had to undergo amputation, whereas 79% had healed their wounds with no relapse. Risk factors for amputation were location (toes), severity of the wound and presence of osteomyelitis. Peripheral artery disease was associated with a poor prognosis, yet was very often neglected.

In spite of being managed at specialized centres that were, in general, following the agreed-upon published guidelines, the prognosis for diabetic foot infection remains poor, with a high rate (48%) of lower-limb amputation."

1. Richard J-L, Lavigne J-P, Got I, Hartemann A, Malgrange D, Tsirtsikolou D, Baleydier A, Senneville E. Management of patients hospitalized for diabetic foot infection: results of the French OPIDIA study. Diabetes Metab. 2011 Jun;37(3):208-215. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21169044

Metformin and exercise

2011-10-26T15:00:00.002+01:00

There seems to be some antagonism between metformin and exercise.

Researchers from Canada looked at the effects of metformin or placebo with exercise on detailed exercise physiological variables in patients with Type 2 Diabetes.

"In conclusion, our study reports several novel findings regarding the concomitant use of metformin and exercise, specifically: 1) increased HR during exercise with metformin, 2) higher plasma metformin concentrations with exercise, and 3) nonadditive effects of metformin and exercise on the glycemic response to feeding. In our opinion, the magnitudes of these effects were small but have the potential to reduce the effectiveness of this therapeutic combination in diabetes treatment. Additional research could help optimize the concurrent use of these important and widely prescribed treatment modalities for diabetes."

1. Boulé NG, Robert C, Bell GJ, Johnson ST, Bell RC, Lewanczuk RZ, Gabr RQ, Brocks DR. Metformin and exercise in type 2 diabetes: examining treatment modality interactions. Diabetes Care 2011 Jul;34(7):1469-1474. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21602430

Chocolate may be good for you ...

2011-10-26T14:53:00.006+01:00

say researchers in the BMJ who conducted a meta-analysis.

"Based on observational evidence, levels of chocolate consumption seem to be associated with a substantial reduction in the risk of cardiometabolic disorders. Further experimental studies are required to confirm a potentially beneficial effect of chocolate consumption." [1]

Of course, making it Fairtrade, makes it even better for you!

1. Buitrago-Lopez A, Sanderson J, Johnson L, Warnakula S, Wood A, Di Angelantonio E, Franco OH. Chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis. BMJ 2011;343:d4488. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21875885

Call for papers - Patient Perspective Case Reports

2011-10-24T11:48:00.005+01:00

BMJ Case Reports is coming up to publishing its 3000th report soon but one aspect that hasn't been explored as much as others is the patient perspective.

The patient's voice is an important aspect to come through in a case report but their input often ends with signing the consent form! It doesn't have to be like that. The consequences of a particular condition or treatment on the person are often important reminders of clinical lessons or the sources of new hypotheses. The experience of patients with healthcare systems can help document and improve clinical performance.

Any e-patients out there that want to work on a patient perspective style case report? I'd be very happy to help.

"SMS for Life" Tanzania

2011-09-29T15:22:00.005+01:00

Heard Alex Nemetz talk at Global Health 2011 about the "SMS for Life" project to reduce malaria in Tanzania.

Alex is the head of mHealth at Vodafone and described how the nurses in clinics were given phones to text the levels of stock to a central system. The problem was that stock was running out in some places but going out of date in others so this simple technological solution using mobile phones helped solve it. The real trick to get the healthcare workers to engage in the project was simple - give them free text bundles for their mobile phones.

GLP-1 agonists and CV risk

2011-09-29T15:02:00.003+01:00

Given the high profile of failures of recent 'blockbuster' drugs in Type 2 diabetes it is not surprising there is anxiety about the risks associated with newer drugs.

In a recent meta-analysis of trials of glucagon-like-peptide 1 receptor agonists (trials that were originally designed to assess metabolic outcomes) the authors conclude there was no evidence to suggest a "detrimental effect of GLP-1 receptor agonists on cardiovascular events. Specifically designed longer-term trials are needed to verify the possibility of a beneficial effect." [1]

1. Monami M, Cremasco F, Lamanna C, Colombi C, Desideri CM, Iacomelli I, Marchionni N, Mannucci E. Glucagon-like peptide-1 receptor agonists and cardiovascular events: a meta-analysis of randomized clinical trials. Exp Diabetes Res 2011;2011:215764. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21584276

Nutritional therapy in diabetes - does it change anything?

2011-09-06T14:48:00.001+01:00

You would think that those people with diabetes in Europe would have undergone nutritional education and therefore have different diets to their non-diabetic fellows. Not so but there are a few small differences. People with diabetes tend to drink more soft drinks but less juice, wine and beer (and sweets). People with diabetes tend to eat a little more vegetables, fish and meat. Otherwise researchers who looked at the populations in the European Prospective Investigation into Cancer and Nutrition Study (EPIC) and the Multiethnic Cohort Study (MEC) found "only small differences in dietary behavior in comparison with cohort members without diabetes". [1]

Changing dietary habits is hard work. Does this mean that nutritional therapy in diabetes doesn't take place, that it is ineffective or that we need to do a lot more of it?

1. Nöthlings U, Boeing H, Maskarinec G, Sluik D, Teucher B, Kaaks R, Tjønneland A, Halkjaer J, Dethlefsen C, Overvad K, Amiano P, Toledo E, Bendinelli B, Grioni S, Tumino R, Sacerdote C, Mattiello A, Beulens JWJ, Iestra JA, Spijkerman AMW, van der A DL, Nilsson P, Sonestedt E, Rolandsson O, Franks PW, Vergnaud A-C, Romaguera D, Norat T, Kolonel LN. Food intake of individuals with and without diabetes across different countries and ethnic groups. Eur J Clin Nutr 2011 May;65(5):635-641. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21346715

Diabetes communication technology - not how but what.

2011-09-06T14:23:00.003+01:00

A chat line helps children and young adults with Type 1 diabetes [1] and mobile phone and web-based collaborative care helps adults with Type 2 diabetes [2]. However, telephone support for underserved ethnic minorities does not seem to help [3].

I feel that these mixed results of these new technologies (many published this year already) mean that efficacy is less to do with the mode of communication and more to do with the quality and relevance of the content of the communication with the diabetes team that is important. To compare these studies we need a lot more information about what was said, how it was said, how the teams were trained and supported, and the frequency of communication.

1. Iafusco D, Galderisi A, Nocerino I, Cocca A, Zuccotti G, Prisco F, Scaramuzza A. Chat line for adolescents with type 1 diabetes: a useful tool to improve coping with diabetes: a 2-year follow-up study. Diabetes Technol. Ther 2011 May;13(5):551-555. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21406010

2. Lyles CR, Harris LT, Le T, Flowers J, Tufano J, Britt D, Hoath J, Hirsch IB, Goldberg HI, Ralston JD. Qualitative evaluation of a mobile phone and web-based collaborative care intervention for patients with type 2 diabetes. Diabetes Technol. Ther 2011 May;13(5):563-569. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21406018

3. Anderson DR, Christison-Lagay J, Villagra V, Liu H, Dziura J. Managing the space between visits: a randomized trial of disease management for diabetes in a community health center. J Gen Intern Med 2010 Oct;25(10):1116-1122. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20556536

Uncertainties in stroke

2011-09-04T15:49:00.015+01:00

Patent Foramen Ovale and cryptogenic stroke

There was a case discussion, at the Friday lunchtime meeting, of a young man with cryptogenic stroke who, on testing, was found to have a patent foramen ovale (PFO). He was offered the option of life-long warfarin or percutaneous closure of the PFO.

The evidence in this area is lacking. [1] PFO is common in the general population and, though a theoretical cause of stroke by paradoxical embolus, it is not proven even with the associated atrial septal aneurysm that may be present.

"Patent foramen ovale, alone or together with ASA, was not associated with an increased stroke risk in this multiethnic cohort. The independent role of ASA needs further assessment in appositely designed and powered studies." [2]

"In patients with otherwise [cryptogenic stroke], approximately one third of discovered PFOs are likely to be incidental and hence not benefit from closure. This probability is sensitive to patient characteristics such as age and the presence of an atrial septal aneurysm, suggesting the importance of patient selection in therapeutic decision-making." [3]

Interestingly the patient presented with a posterior circulation infarct. This is not impossible for an embolus [4] but less likely than a more typical anterior circulation paradoxical embolus. There was also no obvious source of venous thromboembolism either.

Closure may be of benefit [5], and was the option chosen by this patient, but we await the results of more ongoing studies [6] to change the current practice of simply discussing it with the patient and being open about the uncertainty. [7]

(image of patent foramen ovale and percutaneous repair from pted.org )

The current NICE guidance includes a useful booklet for patients considering undergoing the procedure.

Arterial pathologies

Another two cases of stroke were presented both of which involved arterial pathology. One of internal carotid artery dissection with pseudoaneuysm and another of vertebral artery dissection. Both had excellent Magnetic Resonance Angiogram images.

This is another area where the best management (antiplatelets vs. anticoagulation, duration of treatment) is awaiting evidence and both patients were enrolled in the CADISS trial. [8]

1. Irwin B, Ray S. Patent Foramen Ovale-Assessment and Treatment. Cardiovasc Ther 2011 Feb; Available from: http://www.ncbi.nlm.nih.gov/pubmed/21883994

2. Di Tullio MR, Sacco RL, Sciacca RR, Jin Z, Homma S. Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J. Am. Coll. Cardiol 2007 Feb;49(7):797-802. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17306710

3. Alsheikh-Ali AA, Thaler DE, Kent DM. Patent foramen ovale in cryptogenic stroke: incidental or pathogenic? Stroke 2009 Jul;40(7):2349-2355. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19443800

4. Tanaka H, Fujita N, Enoki T, Matsumoto K, Watanabe Y, Murase K, Nakamura H. Relationship between Variations in the Circle of Willis and Flow Rates in Internal Carotid and Basilar Arteries Determined by Means of Magnetic Resonance Imaging with Semiautomated Lumen Segmentation: Reference Data from 125 Healthy Volunteers. AJNR Am J Neuroradiol 2006 Sep;27(8):1770-1775. Available from: http://www.ajnr.org/cgi/content/full/27/8/1770

5. Paciaroni M, Agnelli G, Bertolini A, Pezzini A, Padovani A, Caso V, Venti M, Alberti A, Palmiero RA, Cerrato P, Silvestrelli G, Lanari A, Previdi P, Corea F, Balducci A, Ferri R, Falcinelli F, Filippucci E, Chiocchi P, Grandi FC, Ferigo L, Musolino R, Bersano A, Ghione I, Sacco S, Carolei A, Baldi A, Ageno W. Risk of recurrent cerebrovascular events in patients with cryptogenic stroke or transient ischemic attack and patent foramen ovale: the FORI (Foramen Ovale Registro Italiano) study. Cerebrovasc. Dis 2011;31(2):109-116. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21088390

6. Furlan AJ, Reisman M, Massaro J, Mauri L, Adams H, Albers GW, Felberg R, Herrmann H, Kar S, Landzberg M, Raizner A, Wechsler L. Study design of the CLOSURE I Trial: a prospective, multicenter, randomized, controlled trial to evaluate the safety and efficacy of the STARFlex septal closure system versus best medical therapy in patients with stroke or transient ischemic attack due to presumed paradoxical embolism through a patent foramen ovale. Stroke 2010 Dec;41(12):2872-2883. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21051670

7. NICE. Percutaneous closure of patent foramen ovale for the secondary prevention of recurrent paradoxical embolism [Internet]. 2011; Available from: http://www.nice.org.uk/Guidance/IPG109

8. Cervical Artery Dissection in Stroke Study Trial Investigators. Antiplatelet therapy vs. anticoagulation in cervical artery dissection: rationale and design of the Cervical Artery Dissection in Stroke Study (CADISS). Int J Stroke 2007 Nov;2(4):292-296. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18705933

BMJ Case Reports Indexed on PubMed

2011-08-30T18:39:00.004+01:00

Came back from holiday to find out that the indexing has now been sorted out for BMJ Case Reports so good news to authors and thanks to the publishing team at BMJ.

http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&term=%22BMJ%20Case%20Rep%22[jour]

Will keep an eye on it over the next few weeks but one of my favourite (non-clinical) photos from the time when I was editor is shown here. From the case report "Surfers ankle: a bony spur of the talar neck."(1)

1. Brooks FM, Williams P, Carpenter EC. Surfers ankle: a bony spur of the talar neck. BMJ Case Rep 2009;2009 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21709829

Diabetes articles of interest to 27th August 2011

2011-08-27T22:28:00.002+01:00

Some articles of note indexed on PubMed in the past few weeks.

Training augments the glucose lowering effect of exercise. [1]

People with diabetes from ethnic minority groups may benefit from additional support between visits. However, a study of telephone support in this particular patient group failed to show any benefit. [2]

A study by Diabetes UK and the Department of Health published in The Lancet suggests that adding exercise to a dietary intervention soon after the diagnosis of Type 2 Diabetes confers no additional benefit. [3] The exercise activity was a pedometer-based intervention. This says more about pedometers than 'exercise' in general.

Early intensive multi-factorial treatment in newly diagnosed Type 2 Diabetes detected by screening does not seem to significantly reduce the risk of cardiovascular events after 5 years. [4]

Cochrane review of Chinese herbal medicine for diabetic peripheral neuropathy - no evidence of an effect. [5]

"Education programmes appear to have beneficial effects on improving patients' knowledge of diabetes and some self-management behavioural changes for patients with diabetes on dialysis or with microalbuminuria. Educational programmes appear to have beneficial effects on improving patients' self-efficacy and result in some beliefs changes for patients with diabetes and microalbuminuria. However, only two studies with small sample sizes and inadequate quality were included in this review. There is, therefore, inadequate evidence to support the beneficial effects of education programmes for people with DKD." [6]

Food insecurity has been linked to obesity. In this study researchers "found an association between food insecurity and obesity only among women not receiving food assistance suggesting a possible protective role for food assistance. Providers should consider food insecurity in similar populations when trying to address obesity." [7]

1. Hordern MD, Marwick TH, Wood P, Cooney LM, Prins JB, Coombes JS. Acute response of blood glucose to short-term exercise training in patients with type 2 diabetes. J Sci Med Sport 2011 May;14(3):238-242. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21185229

2. Anderson DR, Christison-Lagay J, Villagra V, Liu H, Dziura J. Managing the space between visits: a randomized trial of disease management for diabetes in a community health center. J Gen Intern Med 2010 Oct;25(10):1116-1122. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20556536

3. Andrews RC, Cooper AR, Montgomery AA, Norcross AJ, Peters TJ, Sharp DJ, Jackson N, Fitzsimons K, Bright J, Coulman K, England CY, Gorton J, McLenaghan A, Paxton E, Polet A, Thompson C, Dayan CM. Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial. Lancet 2011 Jul;378(9786):129-139. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21705068

4. Griffin SJ, Borch-Johnsen K, Davies MJ, Khunti K, Rutten GEHM, Sandbæk A, Sharp SJ, Simmons RK, van den Donk M, Wareham NJ, Lauritzen T. Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening (ADDITION-Europe): a cluster-randomised trial. Lancet 2011 Jul;378(9786):156-167. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21705063

5. Chen W, Zhang Y, Liu JP. Chinese herbal medicine for diabetic peripheral neuropathy. Cochrane Database Syst Rev 2011;(6):CD007796. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21678369

6. Li T, Wu HM, Wang F, Huang CQ, Yang M, Dong BR, Liu GJ. Education programmes for people with diabetic kidney disease. Cochrane Database Syst Rev 2011;(6):CD007374. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21678365

7. Karnik A, Foster BA, Mayer V, Pratomo V, McKee D, Maher S, Campos G, Anderson M. Food insecurity and obesity in New York City primary care clinics. Med Care 2011 Jul;49(7):658-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21430579

Digital whiteboards

2011-07-29T13:38:00.005+01:00

Touchscreens on the wards that allow access to the 'patient administration system' PAS have been installed in Truro. in fact they've been there for a few weeks but we had a presentation of the system (Swift+ - I can't work out who the actual supplier is) at the lunchtime meeting.

The patients' names are shown - as they would have been on the traditional whiteboard - and the bed they occupy. Other administrative information is displayed such as specialty, consultant, expected date of discharge, and icons representng safety issues like falls, dementia and so on. Any member of staff can update the screens and final responsibility for access and accuracy lies with the nursing shift leader. All changes are made on the PAS and this enables a 'live bed state'. This allows more accurate information for hospital management and also the opportunity to access and update the data from PCs during a handover or a multidisciplinary meeting.

Perhaps it would be better to refer to the bed state as a 'real time bed state' to avoid questions about what the dead bed state might refer to.

We discussed representing shared care on the whiteboards especially in the orthopaedic wards where geriatricians actively manage the hip fracture patients especially. The old whiteboards could be adorned with coloured stickers developing a visual summary unique to the culture of a particular ward. This type of 'user' creativity is something that can be overlooked by IT design if they don't involve the people who will use the tool. Also, I think more attention needs to be given to the utility of the data to the staff that are entering it.

Anyhow, the system looks good and can't wait to try it out. Do you wash your hands before or after using the touchscreens (or both)?

Progress testing and educational data mining

2011-07-26T16:29:00.005+01:00

I read George Siemens's interview on O'Reilly Radar, How data and analytics can improve education, and was struck by an example he gave on how education could be changed with the use of analytics.

"In terms of evaluation of learners, assessment should be in-process, not at the conclusion of a course in the form of an exam or a test. Let's say we develop semantically-defined learning materials and ways to automatically compare learner-produced artifacts (in discussions, texts, papers) to the knowledge structure of a field. Our knowledge profile could then reflect how we compare to the knowledge architecture of a domain — i.e. "you are 64% on your way to being a psychologist" or "you are 38% on your way to being a statistician." Basically, evaluation should be done based on a complete profile of an individual, not only the individual in relation to a narrowly defined subject area."

An example of this in medicine is the formative assessment work, progress testing, developed in the Netherlands called Progress Test Feedback System PRoF. It is used at the Peninsula Medical School in the UK. Progress Test (Word Doc). OK it doesn't go as far as saying you are 45% doctor but it does allow students and their tutors to understand where they are on their learning trajectory.

PICME - 3 methods compared for improving prescribing in Spain

2011-07-25T16:57:00.007+01:00

Interesting study from Spain of 3 different interventions, compared to control, to improve prescribing safety in primary care. [1]

control
report (received feedback reports)
session (group sessions)
face-to-face (personal interviews)

No improvement was seen in the report group compared to the control. Face to face was more expensive. The best seemed to be the session group which was the most cost-effective at reducing drug interactions.

An older study on prescribing quality in Spain showed that one-to-one was better than group learning. [2]

It is likely that local context and the exact mode of delivery of interventions explains a lot of the variation in outcomes. What is hard in this type of research is to learn what can be generalised to other circumstances.

Lopez-Picazo JJ, Ruiz JC, Sanchez JF, Ariza A, Aguilera B. A randomized trial of the effectiveness and efficiency of interventions to reduce potential drug interactions in primary care. Am J Med Qual 2011 Apr;26(2):145-153.[cited 2011 Jul 25] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21403177

Figueiras A, Sastre I, Tato F, Rodríguez C, Lado E, Caamaño F, Gestal-Otero JJ. One-to-one versus group sessions to improve prescription in primary care: a pragmatic randomized controlled trial. Med Care 2001 Feb;39(2):158-167. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11176553

Asthma QI in North Carolina

2011-07-25T16:46:00.004+01:00

This quality improvement project in asthma that included health professional education, patient education and free medication did not appear to lessen the rate of return visits for asthma-related symptoms at 30 and 60 days. However, it did describe the rural population of people with asthma and their informal relationship with asthma care.

"In North Carolina, nearly one-fourth of persons with asthma visit an emergency department (ED) or urgent care center at least once a year because of an exacerbation of asthma symptoms. ... Many patients who use the ED for care appear to have mild, intermittent asthma and do not identify a regular source of primary care. Efforts to improve asthma care on a communitywide basis and to reduce preventable exacerbations should include care provided in EDs, as this may be the only source of asthma care for many asthma patients. The project demonstrated that regional, collaborative performance improvement efforts in EDs are possible but that many barriers exist to this approach." [1]

Crane S, Sailer D, Patch SC. Improving asthma care in emergency departments: results of a multihospital collaborative quality initiative in rural western North Carolina. N C Med J 2011 Apr;72(2):111-117.[cited 2011 Jul 25] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21721495

Patients vs. cardiologists #twitjc week 7

2011-07-24T19:44:00.003+01:00

Thanks again to @fidouglas and @silv24 for organising this week's Twitter Journal Club on a paper about the "beliefs" of cardiologists and their patients on the use of percutaneous coronary intervention (PCI) - stents / angioplasty.

The paper by researchers from Baystate Medical Center, Springfield, Massachusetts [1] found that patients were far more optimistic that PCI would reduce their chances of myocardial infarction or death.

My thoughts (5 minutes before the Twitter Journal Club discussion starts) are that it is an interesting paper but it is from one institution with a particularly opaque consent form and the surveys of patients and cardiologists are unvalidated survey tools. It suggests that patients in this facility are not fully informed of the use of PCI before they undergo cardiac catheterisation. To get them fully informed would be a challenge.

1. Rothberg MB, Sivalingam SK, Ashraf J, Visintainer P, Joelson J, Kleppel R, Vallurupalli N, Schweiger MJ. Patients' and Cardiologists' Perceptions of the Benefits of Percutaneous Coronary Intervention for Stable Coronary Disease. Annals of Internal Medicine 2010;153(5):307 -313.[cited 2011 Jul 24 ] Available from: http://www.annals.org/content/153/5/307.abstract

Non-invasive ventilation in the elderly

2011-07-22T13:00:00.002+01:00

Review of a recent paper in Age & Ageing by one of the consultants at Truro for the eldercare lunchtime meeting.

The older person did better than anticipated on non-invasive ventilation (NIV) during acute exacerbations of COPD. [1] The authors concluded "NIV should be offered as an alternative to patients considered poor candidates for intubation and those with a [Do Not Intubate] order."

This has been shown in younger patients over 10 years ago [2] and we are aware that physician predictions of prognosis on ventilation can be unreliable. [3]

The challenge is how and where to manage such elderly NIV patients in the hospital. It needs specialist expertise and sophisticated equipment but clearly has a survival benefit for older patients with acute respiratory failure.

Nava S, Grassi M, Fanfulla F, Domenighetti G, Carlucci A, Perren A, Dell’Orso D, Vitacca M, Ceriana P, Karakurt Z, Clini E. Non-invasive ventilation in elderly patients with acute hypercapnic respiratory failure: a randomised controlled trial. Age and Ageing 2011 Jul;40(4):444 -450. Available from: http://ageing.oxfordjournals.org/content/40/4/444.abstract

Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet 2000 Jun;355(9219):1931-1935. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10859037

Wildman MJ, Sanderson C, Groves J, Reeves BC, Ayres J, Harrison D, Young D, Rowan K. Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. BMJ 2007 Dec;335(7630):1132. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17975254

Velluvial Matrix

2011-07-21T11:26:00.002+01:00

The "velluvial matrix" is a useful phrase that can be hidden in your original writing to catch those who may try to plagiarize your work at a later date.

http://doc2doc.bmj.com/forums/bmj_student-bmj_dean-of-medical-school-admits-plagiarism-think-of-medical-educators

Philip Baker, Dean of the University of Alberta’s faculty of medicine, gave an inspirational speech at the graduation banquet but ... it was not his speech. It was Atul Gawande's speech from the year before published in The New Yorker.

Lessons for those wanting to plagiarize for important speeches to students:

don't
technology will catch you out especially if those darned students have internet access when they are listening to your stolen speech
try and avoid really obvious Google terms like 'velluvial matrix' which will find the original source even if someone clicks the 'I'm feeling lucky' button on Google
preface any stolen part of your speech with "so and so said ... and I quote ..."

Action Learning

2011-07-18T20:45:00.003+01:00

Reading an interesting article using action learning analysis for needs assessment in multidisciplinary teams in the NHS.[1]

Action learning has quite a pedigree in the UK with the work of Professor Reg Revans.

"Revans was convinced - and the proposition became known as Revans' Law - that for an organisation to survive, its rate of learning must be at least equal to the rate of change in its external environment. But learning is hard. Thinking about this at the coal board, and in the NHS, Revans was struck by the potential released by the ability to own up to ignorance without fear of ridicule or reprisal, and the inability of traditional "chalk and talk" teaching methods to solve practical problems, or provide a framework for real human growth. " Guardian, Orbituary, 2003.

1. Staniland K, Rosen L, Wild J. Staff support in continuing professional development. Nurs Manag (Harrow). 2011;18(1):33-37. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21667815. Accessed July 18, 2011.

Whole System Demonstrator

2011-07-15T13:00:00.005+01:00

Good overview of the DoH's Whole System Demonstrator research project by Sharon Eustace, Nurse Consultant at Cornwall Primary Care Trust.

The system uses simple-to-use monitoring and daily questionnaire equipment in patients' homes that communicate with a central system. A nurse checks the patients results and the survey questions each day. The results of this study will be out soon and it would be intriguing to see what aspects are effective. Is it the remote monitoring? Is it the prompting of the patient each day to address the symptoms of their chronic disease? Is it the direct access to health staff?

She explained how she had extended the telehealth project to include incontinence patients in Cornwall.

Diabetes, targets and the elderly

2011-06-17T14:00:00.002+01:00

Good talk from one one of the endocrinologists at Truro on hypoglycaemia in the weekly geriatrics meeting. He covered the Trust's hypoglycaemia policy and the challenge of using the Innolet device with only Insulatard available for the elderly. He also gave a good overview of the cardiovascular risk debate.

I like the sentence: "Don't get too A1c lazy or crazy." which one of the students on our course cited from somewhere.

In particular hypoglycaemia was associated with death in both the agressive and standard treatment arms of the ACCORD study.[1]

There seems to be a difference between the early agressive treatment for T2DM in younger patients without established cardiovascular disease and the later agressive 'tightening' of control in older patients with cardiovacular disease.[2]

This supports the practice of avoidance of hypoglycaemia in the elderly - and the relaxation of HbA1c targets.

1. Bonds DE, Miller ME, Bergenstal RM, et al. The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study. BMJ. 2010;340:b4909. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20061358. Accessed February 5, 2010.

2. Weiss IA, Valiquette G, Schwarcz MD. Impact of glycemic treatment choices on cardiovascular complications in type 2 diabetes. Cardiol Rev. 2009;17(4):165-175. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19525678. Accessed June 22, 2011.

How to plan a CME intervention.

2011-04-27T18:08:00.007+01:00

I missed the #CMEchat on Twitter this afternoon but instead indulged in some curatorial work on analysing the discussion points.

The chat was about the planning, resources, prioritisation and selection of interventions in a Continuing Medical Education programme.

I have roughly classified the responses to the questions about the various stages and their importance is based on the number of tweeps that voiced support or disagreement. I have also "translated" the language a little to make it a little less North American. :-)

In summary the tweeps at #CMEchat said:

Educational planning starts in a number of places but primarily with the target audience and the identification of performance gaps. Priority in planning depends on the size of gap, the disease, cost, convenience and the overall aim of the programme.
Resources are required for planning and this is a complex judgement. Multiple sources are used such as patient encounter data and expert opinion. Caution was expressed on the use of local experts and their views should be validated with other perspectives.
Prioritising needs can be approached pragmatically by deciding how amenable certain gaps are to a CME intervention. "Areas [where] you can actually make a difference" should be prioritised.
Selecting the most appropriate intervention involves a knowledge of the target audience's preferences and choosing interventions that directly support the objectives of the programme.

This ties in quite well with my perception and experience of planning educational interventions. What is lacking, perhaps. from the discussion is talk of theoretical frameworks. Previously 'adult learning' and 'Plan Do Study Act cycles' have been discussed but I don't feel these fully reflect the range of approaches that could be used.

The transcript is available on www.cmeadvocate.com and my summary of the themes is below.

T1 How / where do you begin your educational planning?

ask the audience ... "sometimes with target audience ... depends" @CuratioCME, "polling physicians & healthcare pros ... if they choose topics, they participate" @MedMarketingCOE, "base planning on participant evaluations" @FOREonline ... "ask which patients are problems" @YogAlicia3

performance gaps ... "begin with the gaps" @rmtyner, @CuratioCME, @KansasPCMH

industry ... "request from industry supporter" @pharmaguy, @CuratioCME

"a report will trigger you" @improvecme
"planning begins in several places" @meducate
"start planning as one year ends" @FOREonline
"process for identifying gaps" @meducate
"start with the end in mind" @spelletier
"course directors choose" @FOREonline

prioritization

"validate one person view for larger audience" @meducate
"size of gap and how common the condition" @YogAlicia3
"cost and convenience" @CommPharm
"start with the end in mind" @KansasPCMH

T2: Stage 2, how do you select the right planning resources? how do you know the limitations of anyone resource?

"multimodal" @meducate
"medical claims data" @CuratioCME
"planning process helps find appropriate data" @meducate
"faculty are nationally involved and take [things] into account" @FOREonline ... "KOLs are great when non-academic" @MedMarketingCOE (disagree ... @meducate, @CuratioCME, @CMEComplyQueen, @YogAlicia3)

T3: Stage 3, How do you prioritize needs? (perceived, real, impact, champions…etc.)

impact ... "most likely to impact patient care and integrate successful practice change" @YogAlicia3, "what can I impact today" @KansasPCMH, "areas you can actually make a difference" @SusanBConnelly "greatest need" @improvecme

"Quantitative + Qualitative x impact as a function of resources." @KansasPCMH
"tough ... needs vs. gaps confusion" @CuratioCME
"identify those gaps related to education" @SusanBConnelly

T4: Stage 4, in the same vein, how do you select the best mode of intervention? ---4 what audience?

ask the audience ... "preferred learning format" @CuratioCME, @YogAlicia3
supporting objectives ... "format supporting objectives" @meducate, "purpose" @KansasPCMH (disagree "format not helpful for working backwards" @SusanBConnelly)
focus ... "bite off smaller needs first" @improvecme "Very Good!" @CuratioCME
"little evidence for doing x impacts y" @cmeadvocate
"Methodologies are selected based on physician preferences, accessibility to learners, reach vs cost" @meducate

e-mail efficacy for CME adherence ... and patient communication

2011-04-24T11:06:00.005+01:00

e-mail is a very familiar tool and it is clear from the way it is used by popular online services (PubMed, LinkedIn, Facebook, Twitter ...) that regular e-mails is one way of maintaining interaction with subscribers.

Many of the educational projects I've been involved in have employed some form of semi-automatic e-mail communication to encourage participation from learners.

It was interesting to read some recent papers that have looked at the relationship between engagement and e-mail communication. E-mail clearly has some efficacy but many questions remain. Is it the interactive nature of the content - perhaps in the form of clinical case problems (1) - or is it simply the critical timing of the reminder in the working week (2)? Is it the 'spacing effect' of the reminders with cycles of repetition built into the programme (3)?

There is evidence that email is effective in patient education in the form of weekly and monthly personalised emails (4). Some have even looked at assessing e-mail competencies of clinicians (5).

1. Kerfoot BP, Lawler EV, Sokolovskaya G, Gagnon D, Conlin PR. Durable improvements in prostate cancer screening from online spaced education a randomized controlled trial. Am J Prev Med. 2010;39(5):472-478. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20965387. Accessed April 13, 2011.

2. Houston TK, Coley HL, Sadasivam RS, et al. Impact of content-specific email reminders on provider participation in an online intervention: a dental PBRN study. Stud Health Technol Inform. 2010;160(Pt 2):801-805. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20841796. Accessed April 24, 2011.

3. Kerfoot BP, Fu Y, Baker H, et al. Online spaced education generates transfer and improves long-term retention of diagnostic skills: a randomized controlled trial. J. Am. Coll. Surg. 2010;211(3):331-337.e1. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20800189. Accessed April 24, 2011.

4. Thomas D, Vydelingum V, Lawrence J. E-mail contact as an effective strategy in the maintenance of weight loss in adults. J Hum Nutr Diet. 2011;24(1):32-38. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21114552. Accessed April 24, 2011.

5. Mittal MK, Dhuper S, Siva C, et al. Assessment of email communication skills of rheumatology fellows: a pilot study. J Am Med Inform Assoc. 2010;17(6):702-706. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20962134. Accessed April 24, 2011.

Qualitative analysis of #CMEchat

2011-04-14T10:44:00.009+01:00

Took part in the 2nd #CMEchat yesterday which is every Wednesday at 11am EST on Twitter and, with a bit of regular expression wizardry (1), removed all the @ # and RT stuff from the Twittering.

http://www.wordle.net/show/wrdl/3463096/%23CMEchat_-_13-April-2011

Not sure what the Wordle says but, to me it looks like "good social Learning [in] CME" ... which I think it probably was.

Thanks to Brian McGowan for hosting it. There were 25 tweeps and 225 tweets.

Of course this Wordle is only a bit of a cheat really but I will have a look at the themes and the links to help communicate the discussion to audiences outside Twitter.

1) Regular Expressions in Notepad++ to find Twitter-related stuff.
hashtags
"\#[a-zA-Z0-9_:]* "
end of line hashtags
"\#[a-zA-Z0-9_:]*$"
tweeps' names
"\@[a-zA-Z0-9_:]* "

Frailty syndrome

2011-03-30T22:33:00.005+01:00

Frailty syndrome [1-4] was discussed at the last lunchtime meeting. It was something I've certainly used when commenting on patients but hadn't been aware of the (largely) research definitions of the physical phenotype. As you'd expect it is linked with increased risks of morbidity and mortality.

A commonly cited definition is by Fried:

"a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity" [4]

A good clinical pointer is the 'get up and go' test which is often used in geriatric ward rounds to assess a person's mobility and the presence of difficulties that may not be apparent in the history and examination.

1. Santos-Eggimann B, Cuénoud P, Spagnoli J, Junod J. Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J. Gerontol. A Biol. Sci. Med. Sci. 2009;64(6):675-681. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19276189 [Accessed March 30, 2011].

2. Abellan van Kan G, Rolland Y, Houles M, et al. The assessment of frailty in older adults. Clin. Geriatr. Med. 2010;26(2):275-286. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20497846 [Accessed March 30, 2011].

3. Xue Q. The frailty syndrome: definition and natural history. Clin. Geriatr. Med. 2011;27(1):1-15. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21093718 [Accessed March 30, 2011].

4. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J. Gerontol. A Biol. Sci. Med. Sci. 2001;56(3):M146-156. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11253156 [Accessed March 30, 2011].

Clinical queries

2011-03-21T21:59:00.006Z

A (public) collection of clinical queries for my own CME. Please feel free to comment!

In patients with ischaemic stroke and essential thrombocythaemia some papers suggested referring to haematology.[1] Which patients with stroke and apparent essential thrombocythaemia should be referred?*

Almost all patients on the medical admissions unit round had a C-reactive protein result in the notes. Admittedly I am seeing the 'complex discharge patients' so the diagnoses may not be so straight forward in them but still seemed a high figure to me and unnecessary CRPs are well known in the literature.[2] Which patients require CRP on acute admission? Is there a local policy?

1. Richard S, Perrin J, Baillot P, Lacour J, Ducrocq X. Ischaemic stroke and essential thrombocythemia: a series of 14 cases. Eur. J. Neurol. 2010. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20722707 [Accessed March 21, 2011].

2. Kelly AP, Murphy AM, Hughes R. A retrospective analysis of the use of C-reactive protein assays in the management of acute medical admissions. N. Z. Med. J. 2009;122(1293):3559. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19448789 [Accessed March 21, 2011].

* I've edited this entry following a discussion on #nhssm [March 23rd 2011]. It was based on a patient I had seen recently (as most clinical queries would be). The emphasis is now on my particular learning point and not any details of the case.

Confrontational small group teaching

2011-03-19T15:51:00.007Z

Was introduced to an interesting small group technique by one of the physicians at Truro in the Friday lunchtime meeting.

She circulated an article on Parkinson's disease in the acute hospital (1) prior to the meeting and then formed three small groups of about 5 or 6. Within the groups we had to quiz each other to see if we had read and understood the article.

It certainly worked for me - though it would have helped even more if I had read the article ahead of the meeting. I updated myself on a number of things and have been searching on PubMed for some other reviews:

the importance of early consideration of alternative routes for medication during an acute admission for another illness especially on surgery
the use of rotigotine patches (2) as a logistically easier alternative to subcutaneous apomorphine
the Parkinsonism-hyperpyrexia syndrome (3) which none of us were aware of but several could recognise past patients that may have had it
Deep Brain Stimulation (4)
Duodopa (5)

All in all I think I learnt a lot more from this session on Parkinson's disease than any other I've sat through before. Confrontation stimulates learning and especially if it is done in such a friendly way. Some may find it quite challenging though.

1) Jones SL, Hindle JV. Parkinson's disease in the acute hospital. Clinical Medicine 11(1);84-8: 2011. Available at: http://www.rcplondon.ac.uk/sites/default/files/clinical-medicine-11-1-pp84-88.pdf [Accessed March 19, 2011].

2) Wüllner U, Kassubek J, Odin P, et al. Transdermal rotigotine for the perioperative management of Parkinson's disease. J Neural Transm. 2010;117(7):855-859. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20535621 [Accessed March 19, 2011].

3) Newman EJ, Grosset DG, Kennedy PGE. The parkinsonism-hyperpyrexia syndrome. Neurocrit Care. 2009;10(1):136-140. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18712508 [Accessed March 19, 2011].

4) Okun MS, Foote KD. Parkinson’s disease DBS: what, when, who and why? The time has come to tailor DBS targets. Expert Rev Neurother. 2010;10(12):1847-1857. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21384698 [Accessed March 19, 2011].

5) Karlsborg M, Korbo L, Regeur L, Glad A. Duodopa pump treatment in patients with advanced Parkinson's disease. Dan Med Bull. 2010;57(6):A4155. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20515603 [Accessed March 19, 2011].

Culture and cardiac care quality

2011-03-17T10:49:00.004Z

"High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI."

concluded researchers in the US who looked at hospitals ranked in the top or bottom 5% in mortality rates for acute MI. (1)

What differentiated the best performing hospitals from the weakest was not their use of guidelines or dedicated teams but organisational values, communication, coordination and problem solving capabilities.

From a performance improvement perspective quantitative outcomes of mortality rates and compliance with scientific evidence are only the starting point for designing an educational intervention. The real challenge is correctly analysing and addressing the more woolly qualitative issues that can be the more resistant barriers to performance improvement.

The medical education world is evidence-based obsessed and rightly so. However, it also needs to recognise that the higher educational outcomes of analysis, synthesis and creativity need to be addressed as well as the broadcasting of knowledge.

An old (medic) joke about medical schools' teaching ward rounds is that they often resemble shifting dullness.(2) If the round only involves talk of knowledge and existing evidence and does not explore the organisational and cultural perspectives of patient care then it certainly will be dull (and less effective).

So, this report in the Annals of Internal Medicine makes for interesting reading and opens the field for similar league table research in other therapeutic areas.

1. Curry LA, Spatz E, Cherlin E, et al. What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates? Annals of Internal Medicine. 2011;154(6):384 -390. Available at: http://www.annals.org/content/154/6/384.abstract [Accessed March 17, 2011].

2. "Shifting dullness" being a clinical sign of ascites not the implied meaning of "mobile stupidity".

Social Media as a CME tool cookbook

2011-02-15T10:19:00.011Z

Some recipes for CME using social media. There's been Tweeting about it so I thought I'd do a cookbook. A bit tongue-in-cheek I know but any others want to share some recipes or flame grill any of these?

CME PI(E)

ingredients

network of health professionals in same therapeutic area
a couple of experts in that therapeutic area
2 or 3 facilitators
access to some sample clinical performance data
one secure area on the web for posting anonymised clinical data
weekly email summary tool (aggregating the contributions)
additional media stimulant to aid recruitment

method

Organise a social meeting for the network (via voice / video / chat conference) so that they can get to know each other and offer the additional media if you have it available as an inducement. You may want to use a task as some sort of ice breaker (see Social Media Cocktails below). Allow to mix for 1 week.

Post the sample data onto the secure area. Using the data as an example ask participants to debate which area they want to explore for performance gaps in their practice. This could be done via a #TweetUp cocktail (see below). Leave to cook for 1 week but try to close on consensus early.

With the priority performance gaps identified organise another debate on the interventions, the outcome measurements and timescales. This may require other collaborative tools such as Wikis, discussion fora, Google Docs, conferencing technology, blogs. Organise several 'meet the expert' sessions so that the ideas can be discussed. Keep stirring and remembering to season at weekly intervals with an email summary that includes any offshoots that the network may have developed. This could take a number of weeks. Aim to whisk (i.e. encourage) the participants into some task force or even a community of practice.

Decide a mechanism (blogs, Twitter etc.) for flagging up the progress of each participant. Include these in the weekly summaries. Organise weekly 'show and tell' meetings, preferably synchronous. Eventually everyone (or at least those who will complete) will have the chance to present their experience of the intervention and the outcomes.

When fully cooked present as a document / blog / YouTube / SlideShare. If your CME accreditation system allows present this as evidence of you work at your appraisal else, use it as an example to lobby for its inclusion in future years.

Topic Catchup Snack

ingredients

1 fashionable topic
1 scribe
1 facilitator
1 expert (optional)
case problems in the fashionable topic
several participants

method

Convene the participants in your favourite social media. Negotiate a draft agenda and mechanism for the discussion - 1 hour synchronous or 1 week asynchronous for example. Post the first case problem and debate. The scribe keeps a record of all the points raised. Either post another case from up your sleeve or invite others to contribute experiences of their own. Discuss, scribe, reflect. Continue until time is up.

CME microblogged nuggets

ingredients

1 or more tireless enthusiasts
1 archiving mechanism
1 suitable context
several listeners

methods

Choose your context. This could be hijacking another teaching session or conference. It could be a particular research paper or series of papers in a journal. It could be any sort of event physical or virtual. Choose a hashtag. The tireless enthusiasts microblog on the context in question using the agreed hasthag. The listeners receive, reflect, repost, and throw in questions and points of view to further encourage the already enthusiastic microbloggers.

McNugget digestif

ingredients

the archive of a CME microblogged nuggets session
several participants

methods

As a group reflect on the CME nuggets and pull together the main learning points. Discuss how they can be put into practice. Complete a fuller blog of the whole experience.

Social Media Cocktails

6 degrees of freedom ice breaker. This recipe is blatantly stolen from CPSquare. The facilitator makes a list of participants and assigns them another participant who they have to link to. However, the links must go through 5 other participants. So, for example, two people who share a hobby of cycling, or work in the same City have a link. The task is to find such links between you and the person you are assigned through 5 others. You link to #1, #1 links to #2, #2 links to #3 ... #5 links to the person you are assigned. This is quite a challenge. It basically involves cyberstalking your fellow participants (but in a wholesome bonding sort of way). Leave to mix for at least 1 week.

#TweetUp. Assign a hashtag to your discussion and a time. Invite everyone to make suggestions for an agenda. You could use an open Google Doc for this. Be strict with time. You need to experience them a few times to fully understand the dynamics of this particular cocktail.

Social Media as a CME tool (response)

2011-02-14T12:00:00.004Z

Many barriers remain to be resolved before social media find their proper place in prime time in the world of CME. One of these is an inconsistency of attitudes towards social media by health care organizations. While some organizations, particularly academic medical centers, embrace certain media for educational purposes, others have restrictive policies. After all, no one wants their employees Facebooking on the job. Dr RW Donnell http://doctorrw.blogspot.com/2011/02/social-media-as-cme-tool.html

I agree with Brian's comments things are improving, However, there needs to be more than simply adoption of the new technologies to help in the communication of learning in CME. There also needs to be a change in the perspective of those who 'deliver' CME.

Maybe I'm viewing this more from an international perspective than the American one (where the conversation started) but in my mind there are two issues that need to be addressed by stakeholders:

- a move from broadcast media where 'experts' communicate with 'learners'. It is the learners themselves that need to be doing most of the communicating because the hard topics to crack such as patient safety involve the application of knowledge not simply the acquisition of knowledge. In short a move from objectivism to constructivism i.e. away from 'this is what you should do' to 'here is the problem how do you solve it'.

- a change in the notion of control. Instead of the control (the pedagogy of the design) being directed at what is being learnt and when, it should be control through facilitation of learning communities - giving them the support (data, community building, platforms, feedback, experts) that they may need.

3 key tasks for e-tutors in medicine

2011-02-08T11:49:00.010Z

Link research to practice, show value of learning in each other, and shape the learning ecology.

I've been an e-tutor in medicine for about 15 years principally with an online exam-preparation / assessment website (onexamination.com) and a postgraduate diploma course in diabetes (diabetesdiploma.com). I now work with BMJ Learning.

Recently I've been considering the training requirements for tutors and want to put forward the following three key tasks for 'e-tutors' involved in the distance learning through new technologies of postgraduate medical education. I want to build on these tasks over time and use them to provide perspectives for those wanting to take on the role of an e-tutor. Please feel free to comment.

There have been a number of influences on these ideas including Etienne Wenger's Communities of Practice, Etienne Wenger, Nancy White & John Smith's Digital Habitats, George Siemens and Stephen Downes's Connectivism, Dave Cormier's rhizomatic learning, Vladis Krebs' Orgnet and Lee & McLoughlin's Web 2.0 E-Learning. In fact the thinking is all theirs - this is just my particular perspective on what it might mean to support an e-tutor in their role.

Linking research to practice

Being a tutor in an academic environment, expecially one such as postgraduate medical education, will involve being a guide to the published literature. Linking research to the workplace practice of medicine involves identifying those areas where there is clear evidence.

Asking students to discuss their workplace, the cases that they have seen, the issues that they find challenging enables the e-tutor to then direct them to the relevant studies. After looking at the existing evidence there can then be a discussion on how that evidence can be translated into practice.

Show value in learning from each other

Learning complex tasks such as the practice of medicine means negotiating your identity as a practitioner and exploring the meaning of your practice with others from your same profession and allied professions.

The e-tutor should identify opportunities for demonstrating the value of learning from others and stress its importance for working effectively in healthcare teams.

Shape the learning ecology

Where and how the learning takes place is under some control of the the e-tutor. The learning space is not neutral - it shapes and provides affordances for learning. The e-tutor should act as a digital steward creatively rearranging and choosing the learning ecology as they would rearrange the furniture in a tutorial room. They need to consider suggesting, shaping, developing different orientations and perspectives for the learners. This requires spending time experimenting with new technologies as they become available and having an objective view of how the tools of technology act to support the learning.

The learning ecology has two parts. The first is the current course that is being 'tutored' but the second part is that the connections between the learners should be encouraged and weaved by the e-tutor so that they can be useful outside the course.

Refeeding syndrome and dementia training

2011-01-14T13:24:00.003Z

Not in the same person ... but in the same lunchtime meeting.

Good overview of refeeding syndrome presented at the departmental meeting in Truro. It was based on a recent review in the BMJ (1) but presented with a bit of a memorised case from the wards and a lot of slides. Could have done with less time on phosphates, a few more pictures, some historical perspective and some more time on those clinical circumstances where it can be easily missed - high-dependency unit patients, post-op patients, eating disorders etc.

Whilst in the meeting managed to search BMJ Case Reports for 'refeeding syndrome' and found several cases. Would be good for future meetings to perhaps highlight such a wealth of cases and the associated media that would come with them.

Then had a whistle-stop tour of dementia which apparently counted, in part, for 'dementia training' for all the staff. Marvellous.

1. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008;336(7659):1495 -1498

BMJ on iPad - tool, toy or trinket?

2011-01-13T09:46:00.009Z

The BMJ is the first general medical journal to launch on Apple's iPad tablet computer.

http://resources.bmj.com/bmj/about-bmj/bmj-on-the-ipad

I hear that because of a lack of iPads (see below) the BMJ editor's children and the children of other senior management have fully tested the new journal experience and approve.

In the early days of developing websites programmers had the dilemma of making their content visible on any screen size or being more visual and making it fit the at-the-time-luxurious 800 x 600 pixel screen. They still have that dilemma and the enlightened ones choose the 'any screen' option and some choose the 'best viewed in a something x something screen size'.

The iPad is just a screen. That's its main function - being a screen. It is a certain size since Apple feel that this is the best designed size which it probably is. After all, they know what they are doing. It is exactly 1024 x 768 pixels which is quite generous really.

When you develop an App you don't have to worry about the borders of a browser since you have full control over all the pixels. This is the main function of an App. It delivers the content to you perfectly designed for the screen size that you are viewing.

Add that perfect viewing experience to mobile access and 'key content' from the current issue of the BMJ and you have a tool. At £9.99 for 4 weeks it gives you a rational reason to buy an iPad for yourself and not one of the kids.

I think the business philosophy is great. Get people to buy a highly desirable gadget that kids and other commuters will drool over that costs a lot of money and so makes them look sophisticated and important. Then get them to pay more money to give them a grown-up reason for having it. This not a trinket or toy - oh no - it is an important tool for work.

Here is the formula:

iPad toy + BMJ subscription = happy (smug) doctor

In response to any criticism you just say "I'm reading the BMJ thank you very much".

Apparently a 'sit-in' is planned at BMA House by employees not as a sympathy vote for students but as a protest against the lack of iPads at Head Office. If you have an unwanted iPad toy then please consider those hard-working publishing types who rely on such essential pieces of equipment.

Neurosurgery case

2011-01-11T09:47:00.001Z

Just blogged on a very public neurosurgery case in the BMJ Case Reports Blog which gives an account of the shooting of congresswoman Gabrielle Giffords.

Hypothermia and stroke update

2010-12-10T14:00:00.006Z

Separate discussions of course. These were presented at the Elderly Care departmental meeting in Truro.

Nice update on hypothermia and its management. Disappointed that when I went to search Osborne waves on the internet the 12 lead ECG library's discussion of the 1953 paper was not listed in the search engines. Hmm. There is more competition for ECGs online these days ... or maybe it is that other websites have more useful information. Asked a question at the meeting about bicarbonate and survival and probably sounded as though I was alive when Osborne's original paper was published. Wonder what JJ Osborne's first names were? Never did find out when I researched it earlier.

There was an interesting aspect to the presentation. It was decided to present the case because there was some uncertainty on behalf of the trainee and of the admissions staff as to what the best treatment is for hypothermia. There were no guidelines available but by using up-to-date, which is available within the Trust, they could get quite rapid access to information. It would be good to try and distil that information for a readily available and localised treatment plan for us within the admissions unit. This would be especially useful for this type of unusual condition that does not lend itself to evidence-based practice (as most publications are presumably case reports or consensus views) and is associated with a high mortality.

There was also an update on the 5th UK Stroke Forum that took place in Glasgow. Good discussion on thrombolysis and acute neurosurgery.

Students debate case reports ...

2010-12-02T11:24:00.003Z

... and conclude they'd like to write some.

Just wrote a blog entry about the recent Warwick Medical School Journal Club conference at the weekend.

Case Reports in the era of Evidence-Based Medicine

Calcifications

2010-11-26T14:00:00.005Z

Attended the Elderly Care departmental meeting at Truro where there was an interesting case report of Parkinson Disease diagnosed 10 years previously and who then presented with some features of Systemic Sclerosis and quite marked basal ganglia calcification on the CT.

It was an odd collection of signs and there didn't seem to be any unifying diagnosis. Fahr's disease was discussed and prompted me to find a review. (1)

There was also a discussion about when a CT brain is indicated in 'routine' Parkinson patients.

1) Manyam BV. What is and what is not 'Fahr's disease'. Parkinsonism Relat. Disord. 2005;11(2):73-80. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15734663

A possible future for CME?

2010-11-22T15:23:00.003Z

Pedagogical Ecology is a lovely jargon term originally from Jaffee and used by Nada Dabbagh & Rick Reo in Back to the Future: Tracing the Roots and Learning Affordances of Social Software. In Lee MJW, McLoughlin C (Eds). Web 2.0-Based E-Learning: Applying Social Informatics for Tertiary Teaching. IGI Global; 2010.

They use it to describe a trajectory for e-learning from traditional broadcast media to social software learning environments in tertiary education. Could the same trajectory be true for Continuing Medical Education CME (though perhaps delayed by a few years)?

I've summarized it in this PowerPoint on Pedagogical Ecologies in CME.

I think it is a useful tool for exploring where our current CME activities can be placed, where our learners might be and where we may want to move to (or not).

Appraising rural clinics

2010-11-15T13:34:00.009Z

Just came back from a fantastic family holiday in India organised by Janet and Peter at Brambles Art Retreat. Clare and Molly were the artists and we were the 'support team'. We stayed at the marvellous Karmi Farm which is just North West of Darjeeling and run by Andrew Pulgar-Frame and his mother Deki.

There is also a Karmi Farm Clinic staffed by a young, local man, Siroj who spoke excellent English and had worked there for 5 years. The clinic serves a population of about 3000 who live in the local area in small, humble homes of wood and corrugated steel. The clinic is supported by Nomad Travel and also extensively by Andrew.

The clinic is principally a triage and first aid centre. When we were there it was staffed by Tom and Emily from the UK on a tour of voluntary work. They could handle most things without needing to send patients on the 4 hour bumpy jeep trip to the nearest hospital.

What amazed me most was not the monk who had nearly sliced off his palm with a Kukri that Tom stitched together on and improvised operating table in open air, or Clare using her dental skills in between painting to describe to Tom and Emily how to take out a tooth using a Leatherman multi-tool, or the house visits up extreme paths through the hills, or the copious amounts of "HIT Super Strong (for sale in Sikkim only)" being drunk by all the locals. No ... it was the fact that almost all the booking, follow-up arrangements, and advice was given over the mobile phone by Siroj the local worker who was clearly trusted by the clinic's community.

In this reasonably remote and poor area of West Bengal, where the clinic sometimes lacked lignocaine and dressings, where the people walked in flip-flops for several hours to seek advice they had a local community health care worker who dealt with a community twice the size of most single-handed GP practice lists using mobile technology.

I left wondering how best to practically support such an outpost or others in similar situations in developing countries. Local, trusted, community health care workers may be providing a lot of care to some of the most vulnerable of people and often outside any formal Government health programme. What can be done to support them?

Here are some ideas:

regular face-to-face support - this is the first thing that Siroj asked for - volunteer medics especially in the unpopular monsoon seasons
more formalised telemedicine perhaps. Where a decision to 'have a go and stitch it' or 'send it to the local hospital' is being made then a phone-a-friend option might be most welcome. This is a highly specialised and urgent discussion which doesn't lend itself to the more convenient asynchronous technologies like social media.
semi-automated collection of data - so that suggestions could be made (remotely) for further support or training
local / regional networking. I know some medics in West Bengal and one whose family runs a small hospital not far from this area. Network weaving by linking them to the clinic would help. One issue that had been raised previously was the apparently high incidence of hypertension. After being there a week it seems that it may be the measurements that were probably high not the blood pressure itself - after climbing a hill your blood pressure will be high and aneroid sphygmomanometers are not as reliable as mercury ones. Perhaps a local contact could source better equipment? I found the Indian Hypertension Guidelines and emailed them to Tom - printing them out at Karmi farm is the trick.
getting an experienced community health care project leader / researcher / team to conduct a 'rapid appraisal' and involving the clinic's population

Would be interested to hear some others.

TILT - microblogging your learning

2010-10-12T09:17:00.002+01:00

Just caught up with news of this Today I Learnt That ... pilot from the TRIP database guys Jon Brassey and Chris Price.

Nice one ... and it's another 4 letter acronym beginning with 'T'!

Not to be confused with FT's tilt (note the lower case) which is a digital news site about 'tilting' markets?

TILT looks like a Web 2.0 way of microblogging your own learning especially when reading the evidence-based medicine summaries on the TRIP database. Since they have now got 10,000 registered users it would make great sense to give them some sort of simple way of tracking their reflections. Having a dedicated tool used by this particular community has advantages over, say, a more general microblogging tool such as Twitter since the learning may get mixed up with what you're eating for breakfast or which train you're on. There's the challenge too and I wonder if we may see some linking up of other online tools via fancy tagging. Hey ... the #tilt hashtag is not really widely used so I'd start posting it to reserve it!

Online vs. face-to-face learning

2010-10-12T08:56:00.002+01:00

"Focussing on the individual learner, their needs and encouraging their reflection, is more important than fancy online tools".

Reading the report Evaluation of Evidence-Based Practices in Online Learning: A meta-analysis and review of online learning studies. U.S. Department of Education. Revised September 2010.

This is a systematic review of the literature (the principle databases were ERIC, PsycINFO, PubMed, ABI/INFORM, UMI ProQuest Digital Dissertations but manual techniques were also used) 1996 - July 2008 of studies looking for experimental or quasi-experimental studies evaluating face to face and online learning with objective measures of learning. 1132 abstracts screened, 176 studies selected of which 99 used for analysis and 77 used for narrative synthesis.

The authors concluded:

"Few rigorous research studies of the effectiveness of online learning for K-12 students have been published." Many of the studies included in this report were from higher education such as medical training. So, even more interest from a medical education perspective.
Face to Face plus online learning is better than online learning alone which is better than Face to Face alone. The authors warn against over-interpretation of this finding since the differences may be due to factors other than the media per se. These factors could include content, pedagogy and learning time.
Instructor-directed learning and collaborative learning (peer to peer) were effective but individual learning was not.
"Most of the variations in the way in which different studies implemented online learning did not affect student learning outcomes significantly." 13 different learning practices had been identified as potential sources of variation but none were found to be.
"The effectiveness of online learning approaches appears quite broad across different content and learner types." Undergraduates, graduates and professionals all seem to benefit from online learning.

Also, they observed that studies tending to conclude the following:

Blended and purely online learning within a single study have similar effects.
Video and quizzes don't seem to have an influence on the amount that is learnt online.
Learner control and reflection enhances learning.
Guiding groups of online learners tends to influence the way the interact but not the amount they learn. Compare this with the beneficial effect of guiding individuals online.

It is great that this type of work is regularly undertaken in the US. We owe a lot to the public funding and open publication of such research.

I wonder if the conclusions here should be that online learning allows for more opportunities and time for learning, good teaching works regardless of the media used ("Effective teaching transcends course format") and focussing on the individual learner, their needs and encouraging their reflection, is more important than fancy online tools.

Diabetes education project

2010-10-07T11:25:00.007+01:00

Started an international diabetes project yesterday for primary care physicians in four different countries. The educational intervention is based on the social learning theory Communities of Practice¹. It will be evaluated by colleagues in Canada - hopefully across the two languages - and written up early next year.

There was a lively discussion at our orientation session in Cardiff (thanks all) but all too brief. I hope the platform that we've developed will help extend the discussion.

Before the session we asked some of the GPs to send details about their current clinical practice and plugged them into Wordle to create a visual summary of the themes and issues - a technique I picked up from Bronwyn Stuckey (thanks @BronSt).

Don't know what it means but, like reading tea leaves, it helps to stimulate conversation.

Looking forward to the online discussion and perhaps the possibility of breaking out of our basecamp.

1. Etienne Wenger. Communities of practice: learning, meaning, and identity. Cambridge University Press; 1998. Associated website at: http://www.ewenger.com/theory/ .

Sharing presentations

2010-10-01T11:32:00.013+01:00

Have a presentation next week where some of the participants can't attend in person so we will, at another time, go through the slides with them remotely but the presentation has been developed by someone else in Office 2007 .pptx format. Boo!

Whilst it is possible to share this with various web conferencing software by sharing screen displays they all rely on either Flash (DimDim), Java (Elluminate) or both. Whilst these are excellent services they can have some 'set up' issues. I'd like a much smaller barrier as this is the first meeting of the group.

I would prefer to present this using a simple interface that needs no logging in and can be used whilst talking over the telephone. i.e. Google Docs. However, Google docs works with ppt files and not pptx files. Also if I open the presentation with Open Office and save it in Office 97/2000/XP version .ppt format then Google thinks it's corrupt. Hmm I wonder who is corrupt. It couldn't be Microsoft could it trying to force people to use a new version of their Office software? (Got a copy of MS Office 2003 on a laptop so will have to go there and do a conversion I suppose. But really ... why?)

Recently seen some excellent examples of document sharing using Google Docs on the CPsquare Foundations course. I think the ability to use simple collaborative and white boarding tools with low barriers for participation is very important for engaging learners especially those who are less experienced with such online participation. Being inclusive is more important than choosing a particular technology. Something that just uses the browser without any need for plugins would be ideal.

Any suggestions for very simple whiteboard viewers?

skrbl looks good but doesn't seem to do pictures / screen shots
Google Docs Drawing seems better but would be a little clunky for a long presentation

Geeking out with a Communities of Practice Workshop

2010-09-13T12:22:00.002+01:00

The Foundations of Communities of Practice Workshop, September 2010 course from CPSquare starts today.

http://cpsquare.org/edu/foundations/

I enrolled on the course to learn more as a current project I'm involved with includes an attempt to stimulate and support a Community of Practice among doctors who care for people with diabetes. Having read the books (http://www.ewenger.com/pub/pubbooks.htm) and the theory I felt some practical discussion and experience would be helpful.

The best way to learn about a particular learning theory is to learn about it by using it to learn about it.

Communities of Practice are not discussed widely in medicine but they clearly exist. They are far more openly promoted in other industries including local government in the UK which an old friend pointed out over the summer.

However, doctors are a strange bunch and sometimes if you tell them you want to put them into a 'community of practice' their initial response would be to say no thanks. They say that when they talk about their clinical work but in other aspects they leap into communities of practice. There are quite a few medics in the cycling group "One and All". It was very interesting listening to the informal discussions about the practice of cycling during the ride, afterwards at the cafe and later on the Facebook page. There are also strong issues about negotiation of identity. There are cycling outfits (you can imagine it) that reflect membership of the club from those on the periphery and one person was even wearing new branded socks which someone else very much wanted to have. Where next?

Anyhow, looking forward to geeking out with other CoP enthusiasts later today.

iPhone App for 24HourLondon launched

2010-06-27T21:00:00.001+01:00

Web interface, website and iPhone App sorted.

Been working with Emma for the last few months on developing the web database that delivers the details of the venues to the iPhone App and its associated website with funky graphics designed by Corin.

http://24hourlondon.co.uk/

It has been really enjoyable - though a little challenging working with family and another developer all at a distance - and it is great to see it finally listed on the Apple Store as 24hourlondon for iPhone. Well done Emma.

Basically there is a large database of thoroughly researched late night venues. The iPhone App tells the database its geolocation and the database calculates distances and lists those venues that are nearby. Want to carry on past your normal bed time? 24 Hour London is here to help.

I get the feeling that this sort of work is currently over-priced. The development costs are quite high in comparison to the relative simplicity of the technology. I'm sure that in coming years developing applications for smartphones is going to be cheaper. The real value is in the "content" - the details of the venues that have been researched and are more reliable than simply searching the web for details that may be very out of date. Content is king ... and always was.

Now we've got the web API sorted out we'll have to do the same for Android phones.

Dermatomyositis

2010-04-29T14:00:00.011+01:00

Lunchtime meeting in Truro on Dermatomyositis with a presentation of two cases. Excellent reminder of this condition which seems to be very popular at lunchtime meetings wherever you go.

The additional images and differential diagnosis slides were particularly good and came from DermNet NZ.

There's also a good example of how the rash appears on darker skin at BMJ Case Reports¹.

1. Tristano AG. A woman with muscles pain, weakness, and macular rash. BMJ Case Reports. 2009;2009(aug27 1):bcr0620092027-bcr0620092027. Available at: http://casereports.bmj.com/content/2009/bcr.06.2009.2027.full [Accessed May 6, 2010].

Women in Kenya are 50 times more likely to die in childbirth than in the UK.

2010-04-13T12:25:00.002+01:00

The Lancet has published Maternal Mortality Rates for 181 countries (1).

The Guardian has also published the maternal mortality rate table in its blog.

Looking down the table with our particular interest in Kenya it looks like they have made some progress in reducing the rate in the last 20 years but very little. Even though some of the discussion in the last few days has been on why the UK has not improved or why it is "worse" than Albania it is sobering to think that women in Kenya are 50 times more likely to due during or after childbirth than women in the UK.

1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010 Apr 9

Started a JustGiving page for Mercy Rescue Trust

2010-04-01T00:54:00.003+01:00

After some fiddling managed to get my JustGiving page up for the Mercy Rescue Trust.

http://www.justgiving.com/DeanJenkins

Has the doubtful strapline of "sponsor us having a good time" or something like that.

Punk IPA - BrewDog Brewery

2010-01-13T23:15:00.004Z

Very hoppy IPA with 6% ABV.

Pale yellow with nice foamy head. Straw, mildly fruity and light caramel nose. Quite a bite on tasting - "resinous" with a long dry bitter end like licking someone's armpit - very punk.

http://www.brewdog.com/punk_ipa.php

Transatlantic influenced IPA. How many hops can we stuff in it?

Nice but would find it hard to drink two.

Is an 80-lead ECG worth the extra 68 leads?

2009-12-14T13:02:00.004Z

Although an 80-lead ECG may show evidence of a full thickness myocardial infarction not seen on a 12-lead ECG it does not necessarily follow that treating the patient differently will lead to a better outcome.

Commenting on Jason Winter's post about 80-lead ECGs on his ECG blog which gave an overview of a recent paper (1).

1. Hoekstra JW, O'Neill BJ, Pride YB, et al. Acute detection of ST-elevation myocardial infarction missed on standard 12-Lead ECG with a novel 80-lead real-time digital body surface map: primary results from the multicenter OCCULT MI trial. Ann Emerg Med. 2009;54(6):779-788.e1. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19766352.

Vitamin D and Health

2009-12-10T15:36:00.004Z

Although heavy going at times I attended an interesting update on Vitamin D at Truro today. Basically Vitamin D seems ... well ... vital not only for bones but for soft tissues as well(1). It would be interesting to explore the relationship with diabetes, Type 1 in particular, in more detail. I had been aware of a lot of the work but haven't looked into it ... Vitamin D being a dreary subject I suppose. I wonder why that is? Is it because its been written about for such a long time. If it had a name like 'pro-hormone D123' it might not induce indifference so readily.

The conclusions seemed to be that trying to raise your Vitamin D levels to at least 75 nmol/L is another reason for cycling to work and if we go surfing to wear a shorty wetsuit. Marvellous.

1. Bouillon R, Carmeliet G, Verlinden L, et al. Vitamin D and Human Health: Lessons from Vitamin D Receptor Null Mice. Endocrine Reviews. 2008;29(6):726-776. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2583388/?tool=pubmed [Accessed December 10, 2009].

#hcsmeu - mostly about #FDAsm (or is it #fdaSM?)

2009-11-13T16:25:00.010Z

Today's Tweetup on #hcsmeu was mostly dominated by the current Food and Drugs Administration public hearing on social media.

I think it is great to have this debate but it is more than simply working out how best to distribute regulated information on the internet. The role of the prescriber is important and it can be overlooked in the rush to create more e-patients. Open information about drugs and treatments is important as well as promoting digital literacies. However, those seeking the information must also be able to judge whether or not the treatment is indicated or relevant. This requires a broader perspective ... and is why they will still need to talk to their doctor. The challenge with bringing the prescriber into this arena is that there is a conflict between the openness required for effective social media and the confidentiality needed for a personalised consultation.

My summary of the views from the #hcsmeu session is:

Q1 What can EU healthcare learn from this week's FDA Social Media hearing?

FDA are right to engage in this way. It seems they may already have draft guidelines in mind.
How quickly will the FDA be able to publish? Will it already be out of date or will the advice be too general for the expectations of those advocates social media?
Will / should / could the EU follow the FDA?
Is it more about language since English speakers around the world will be able to access American pharma social media anyhow (unless censored)?

Q2 Google, Yahoo call for expanded online drug ads; good for patients?

Good for advertising revenue and possibly good for patients.
Better to have regulated pharmaceutical information than hearsay and misinformation.
This may translate into more direct promotion of disease portals in the EU where direct to customer promotion (i.e. drug name appearing with drug indication - thanks @FarmerFunster) is not allowed.

Fascinomas at lunchtime

2009-11-13T11:15:00.003Z

Went to the grand round in Truro again yesterday and there were two cases presented. Both were quite unusual and presented a real diagnostic challenge to the admitting teams. They were described as fascinomas.

Blogging your CPD is a bit of a challenge when you can't discuss the details of the cases. However, suffice to say it was a very useful reminder of (1) the possible rare causes of right heart failure, and (2) to always keep sepsis in mind when there is an unusual presentation and especially when the CRP is 300.

The small cakes were very good but the coffee is barely drinkable. Haven't tried the pasties yet as they all seem to go very quickly. Will be more forthright in the future.

#hcsmeu - eats shoots and leaves.

2009-11-06T15:01:00.006Z

Wish I had assigned more focussed time to it and a better tool than plain old twitter.com but managed to catch up with #hcsmeu 'Tweetup' today.

The debate on Health Care Social Media Europe focussed today on the three questions:

Experiences in EU of sites rating physicians and/or hospitals? Which are the constraints?
What are most effective ways to build a healthcare (provider and patient) community? Are there any ressources available?
If DTC advertising to patients in EU is banned, but SM is global, can industry utilise SM to give EU patients info online (in keeping with the EC rules)?

The full list is available as a Google Doc.

It was quite hectic and I would have preferred a more standard chat interface as I had to reload the twitter search every now and then. My feeling was that there was a lot of direct unguarded talk (understandable with the 140 character limit) with the intent of defining what the social media business model would be in health. Gritty, informal and refreshing with lots of different perspectives. The medium favours this type of 'messy' discussion and, in a way, to understand what others think is a good introduction for making contacts but perhaps not about understanding the subject.

Analysing the themes of the first two questions (using the transcript) to me it looked like the following views were expressed:

Change seems inevitable.
Locality and mobility may be more important than ratings in patient choice especially in rural settings.
There are problems with patient feedback (in a simple 'rate your doctor' setting). How can it be made more objective?
A successful system needs the right design of community and the right mix of patient and professional, leadership and community.
Nobody pointed to very successful doctor / hospital rating sites but it was obvious there were many successful 'community' sites. [In my view mostly disease-specific.]
Would an emergent design be better?
There are difficulties with sustainable business models.
Difficult feedback from patients or communities can create even more problems with clinical governance.

As for Q3 I think the answer is simply yes ... but that may be me being too simplistic.

This sort of discussion needs more time and consideration than a quick hour of shooting off Tweets and leaving in time for lunch. However, its focussed nature and the fact that it endures after the event allows for additional networking between the attendees (such as pharmaguy introducing me to an example of an effective community before Web 2.0 as in DIABETES-EHLB) and analysis of comments (such as above).

Very interesting. Thanks Andrew Sprong and Silja Chouquet.

Links:

http://www.healthunlocked.com/ (example entrepreneur-led community site currently in beta testing)
Docinsider.de blog
PharmaTimes: EU drugmakers agree breakthrough on patient information. 5/Nov/2009
Imaginatik Webinar "Crowdsourcing in Healthcare"

BTS Emergency Oxygen guidelines at Truro

2009-11-05T14:57:00.003Z

Attended the Medical Unit's lunchtime meeting at Royal Cornwall Hospital for the first time today where they had a talk on the recent BTS Emergency Oxygen Guidelines from one of their Oxygen champions Dr Coutts. The presentation was largely based on the BTS's lecture for doctors on Emergency Oxygen use in adults with an emphasis on the practical changes that will occur in the Trust.

Oxygen therapy is still variable and suboptimal (1). The Trust will adopt saturation targets of 94 - 98% for most patients and 88 - 92% for those thought to be at risk of Type 2 Respiratory Failure. Oxygen is to be prescribed on treatment charts as this is apparently not commonly done - was routine in Bridgend when I was there. However, in Truro this is going to be with the use of stickers that make the saturation target, mode of delivery and flow rate explicit. There was an interesting discussion about how they are going to try and extend this practice across the PCT. Overall was a good informal reminder of Venturi masks, nasal canulae, reservoir bags, flow rates, oxygen dissociation curves (2) and the boundary disputes between paramedics, physicians and intensivists. Reminded of the editorial a few years ago in the BMJ (3).

I wanted to pop a question at the end to the junior docs such as "does anyone know a condition where patients present critically ill to A&E and where oxygen therapy is contraindicated? (answer = paraquat poisoning)" but thought better of it. Was my first time as a guest after all.

1. Hale KE, Gavin C, O'Driscoll BR. Audit of oxygen use in emergency ambulances and in a hospital emergency department. Emerg Med J. 2008;25(11):773-776. Available at: http://emj.bmj.com/cgi/content/abstract/25/11/773 [Accessed November 5, 2009].

2. Thomson AJ, Drummond GB, Waring WS, Webb DJ, Maxwell SRJ. Effects of short-term isocapnic hyperoxia and hypoxia on cardiovascular function. J Appl Physiol. 2006;101(3):809-816. Available at: http://jap.physiology.org/cgi/content/abstract/101/3/809 [Accessed November 5, 2009].

3. Thomson AJ, Webb DJ, Maxwell SRJ, Grant IS. Oxygen therapy in acute medical care. BMJ. 2002;324(7351):1406-1407. Available at: http://www.bmj.com [Accessed November 5, 2009].

Updating myself on CCK09

2009-11-01T22:27:00.001Z

Have been busy with other things lately and have not really been following the CCK09 course. It does seem generally a little quieter and that might reflect a "burn out" of some of the early enthusiasm.

Managed to catch up with the reading over the last few days and updated my concept map.

http://share.xmind.net/dean_jenkins/connectivism/

I am feeling far more satisfied with the rigour of debate that this learning theory has undergone but it is ironic (and intentional) that it is itself distributed and emergent.

There are works by Siemens and Downes that link to a lot of related theory but they are stored in many places in different forms: articles, videos, teleconference sessions, photos of whiteboards etc. The debate emerges through CCK08, CCK09 and other related networks and it is certainly impossible for any individual to find it all and know it all.

Using zotero for referencing.

2009-10-23T12:07:00.001+01:00

I've just installed and I've been using zotero which is a free Firefox plugin.

It's seems very good at storing references (just 1 click is needed when reading an abstract on PubMed) and, if you set vancouver style as the default, you can just drag and drop a fully formatted reference into a web form. Like this¹. OK it doesn't do the author names exactly like we are used to on our diabetes diploma course but in the zotero record in your library the reference also includes the PMID, the DOI, the ISSN of the journal and so on. I think it is very useful.

Has anyone else had any experience with zotero? Or are there even better ones out there?

David M Nathan et al., “Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes,” Diabetes Care 32, no. 1 (January 2009): 193-203, http://www.ncbi.nlm.nih.gov/pubmed/18945920.

Emerging technologies in Africa start page

2009-10-23T09:23:00.001+01:00

This is my Personal Learning Environment for the Emerging technologies in Africa course led by George Siemens and Dave Cormier.

Google Group: http://groups.google.ca/group/africaiet09/about?hl=en
Moodle: http://ltc.umanitoba.ca/moodle/course/view.php?id=70
Delicious bookmarks: http://delicious.com/search?p=AfricaIET09

George's TEKL (was learnometer)

2009-10-21T10:11:00.000+01:00

Anne-Marie prompted me to look at George Siemen's latest blog post on Technologically Externalized Knowledge and Learning which makes for fascinating reading. At least I assume that was the one she meant!

The big question is when is this concept tool going to be available? Maybe someone has already written the iPhone app already.

The 'we' not the 'I'

2009-10-20T23:53:00.001+01:00

Reading this Pharma Strategy blog which resonates with the ideas being discussed on #CCK09.

http://www.pharmastrategyblog.com/2009/10/its-all-about-we-not-i.html

"That's what sharing and engaging is all about, sharing ideas and information willingly, leading from the front and setting a good example for others. New technologies and social media can be a wonderful tool for finding new people, new blogs, new ideas and plenty of spirited exchange. Fresh inspiration from others can set off a new creative spark and stimulate new content and more sharing, and so on ad infinitum."

Did we ever pay for content?

2009-10-08T13:01:00.002+01:00

Reading Paul Graham who makes some very interesting points about publishing content and the internet era.

Knowledge ... not as I know it.

2009-10-08T13:00:00.002+01:00

Reading with interest about knowledge and what it is. Haven't been so deep in philosophy before but find it a very interesting question.

Should we be concerned with a theory of knowing rather than theories of knowledge? Ernst von Glaserfield's 2500 year summary of sceptical thought provides a background to what he describes as radical constructivism.

Is knowledge about a thing or does it emerge from the interactions we have (without ever being a thing)? Stephen Downes goes deep into the Emergentist Alternative and builds the case for connectivism and "e-learning 2.0".

Do you wear a watch?

2009-10-04T12:24:00.000+01:00

Read with amusement the list of 50 things that are being killed by the internet published by the telegraph recently.

One that struck me was the watch (number 10) but I've been going off the watch for a lot longer than the internet was around. Why wear a watch when there are plenty of places to see the time?

You need to know the time when you have to be somewhere at a certain time or do something at a certain time. This means that you are probably around people and civilisation. There are numerous clocks around you and you probably carry a mobile phone or a PDA, and there are plenty of other people around you to tell you the time. Time is less critical now with the ubiquitous connectivity that's available so you can always rearrange appointments and punctuality is something that is also being killed off (number 5). So, when you most need the time you probably don't need a watch.

When you don't have access to other ways of telling the time you are probably away from society in the country, or on a beach in your swimsuit where clocks, mobile phones, PDAs and other people may not be around. But this is when you least need to know the time because you are less likely to need to be somewhere at a particular time. So when you most need a watch to tell the time you probably don't need to know the time.

Either way you don't need a watch.

Social (and learning?) evolution in terms of TIMN

2009-09-29T14:54:00.001+01:00

Found David Ronfeldt's blog via Spinuzzi's blog posting on one of his RAND papers.

"According to my review of history and theory, four forms of organization — and evidently only four — lie behind the governance and evolution of all societies across the ages:" Overview of social evolution (past, present, and future) in TIMN terms

TIMN stands for: Tribal, Institutional, Market and Network.

This is a compelling way to look at the evolution of society and wonder if it can be applied to medical teaching and learning too.

Tribal - apprentice and mentor within a particular practice

Institutional - traditional university / college teaching

Market - the open market for CME/CPD and courses

Network - courses such as the Postgraduate Diploma in Diabetes at Cardiff perhaps, Wenger's communities of practice living in digital habitats, CCK09 of course ...

My only anxiety is that evolution suggests a one-way and one correct way for a society to evolve. Working in a network with social equity, justice, information overload and rewarding connections but I'm sure there are times when the other forms of organistion would work better.

Reflections on CCK09 week 2 - networks

2009-09-29T10:51:00.007+01:00

Had an interesting week looking at network properties as part of Week 2 of CCK09.

Building my own network (nature vs. nuture)

Read Imreli Aro's introduction of herself to the course and in particular her 10 rules of becoming a social mediator. Asking questions seems such an obvious way to start networking and I've found it particularly useful during this week. Have built contacts and even met one for lunch who introduced me to a new restaurant on our campus (thanks Anne-Marie)! There are a number of health professionals on CCK09 and hope to connect with them some more.

I wonder what the balance should be between actively seeking to make a network and allowing a network to develop by serendipity. Which is the more effective in terms of time and effort, efficacy of learning, complexity of knowledge etc.? It must be a balance but remembering the qualities of others in your network is something I find quite a challenge especially when the initial contacts are very brief. In 'the real world' it would take several meetings to build up a rapport and this connectivism network building feels a little like ruthless speed-dating at times. I think time and discovered shared interests will be the best means for me.

Have initiated a lot of networking outside the CCK09 course as well and will build on my role as 'broker' between different networks and communities. Found the facebook tool to map my own personal network of friends very interesting. It allowed me to visualise hubs (my sister) and brokers (a friend who introduced us to a charity we are now involved with) in my own personal network.

An interesting point has appeared when looking at the discussions of two people in my network both doctors talking about patients who read medical information on the internet and form fantastic disease-specific communities such as 'survive the journey' for Cushing's disease. You would think that doctors would be useful people in those online communities but they are not. The strength of the connections between the members of the community is much stronger than that of any doctor with the community.

Network complexity / analysis

I had read about scale-free networks previously but this week has allowed me to bring several of my own nerdy interests together. Fractals, Mandelbrot's (mis)behaviour of markets that suggests the complexity of market forces could be explained by its 'scale-free' nature, how the brain works, small-group teaching techniques, and specialist communities. This has been connection making at a conceptual level and has allowed me to look at learning with a different perspective. most interesting. Whether this is 'connectivism' or just being inspired by reading other people's opinions and challenges is the big question ... for my CCK09 thoughts. Added a lot about network properties and Downe's design principles to my concept map of connectivism.

Reading Barabasi's Scale-Free Networks: A Decade and Beyond raised a question about how common scale-free networks are. Scale-free networks are a feature of many but not all networks in nature. In particular we do not know if the central nervous system does behave like this as we have no map of its connexions (the connectome) or any way of generating an accurate model. I wrote about it in response to a thread called 'the connection' started by Ken Anderson where I said,

"The key part of this which I am not clear on is how can we be certain that network properties that exist in one system can be extrapolated to another. Not all networks are best explained by a power law for example. How can our understanding of complex networks (WWW, society, models of scale-free networks on a computer or in a maths expression) help us explain the characteristics of networks which we don't understand very well - like the CNS for example. Likewise, in the other direction, how can our insight into human cognitive processes be extrapolated to explain the dynamics of personal learning networks.

Hmm. Best leave it there with a big question mark and hope someone else pitches in to dig me out of my hole. ?"

Concept map of connectivism

2009-09-24T14:23:00.004+01:00

I started creating a concept map on connectivism for my learning on CCK09 a few days ago and have been updating it since. Added some more links about scale-free networks today and started a 'strengths and weaknesses' of connectivism section.

http://share.xmind.net/dean_jenkins/connectivism/

I remember Tony Buzan on television as a kid and used 'mind maps' quite extensively through school and university. I was quite frustrated with their use in medicine since - from my perspective - the concepts in medicine were quite easy to understand but the reams of lists and facts were not. Mind maps were not of much use. I was even more surprised at the success of a book in medicine that included the authors' mind maps to help students revise. It seemed a rather odd way of communicating knowledge since one person's mind map may be different to another's ... and isn't most of the learning in creating the map itself?

So it is quite interesting to return to mind mapping using software rather than pencil and paper. XMind allows me to easily share the map with others and display it for them without the need of additional software. It also works on my laptop (Windows) and my PC (ubuntu). I'm going to try and keep it simple and not add specific XMind features so that it is compatible with FreeMind. In a year's time my choice of mind mapping tool might be very different.

I'd like to explore collaborative concept mapping and wondered if anyone on CCK09 reading this would care to comment on any particular part of the map. Does my concept map network resonate with my learning network? Do we share the same misunderstandings? Will the true insights (if any) be spread? Is there a concept map wiki version I wonder? That would be an anarchic tool.

#pddcf

2009-09-24T11:22:00.000+01:00

I've started tag aggregating on a course I teach and have tried to introduce the tag #PDDCF standing for Postgraduate Diploma in Diabetes at Cardiff University.

Here are some shortcuts.

Twitter
Google

Reflections on CCK09 Week 1

2009-09-20T22:36:00.002+01:00

What is Connectivism?

Was a stimulating first week. Not quite what I expected and I must say I started off as a skeptic. However, there seems to be something in the 'theory'. The observation that this sort of learning is happening and appears to generate knowledge and understanding about topics quite clear. Connectivism does explain a lot of the activities. I am reading Wenger's Digital Habitats and going over his 'communities of practice' theory at the same time and this provides an interesting diversity of viewpoints.

The pace of adoption and the range of different tools used by the other 'students' on the course is quite incredible and I feel thoroughly 'immersed' as Downes would say. Gained experience with Ning, Yahoo! Pipes, Wiki, Blogs, tag hacking, RSS, Elluminate and Friendfeed. Watching how others use them is an excellent way to learn but also the use of the learning techniques explained by connectivism is a great way to learn about connectivism itself.

There are a lot of CCK08 attendees in CCK09 and I wonder what the proportion is. I feel quite humbled to be among some very deep thinkers and maybe the whole thing will make more sense if I come back in CCK10!

Defining terms has helped my understanding and have worked on a wiki page for a Connectivism Glossary. I found that writing out the jargon and then finding or inferring the definitions from previous papers by Siemens and Downes helped me piece together what the theory meant. More established theories have plenty of books on the subject which allow plenty of time to explain the jargon. I suppose this approach is a quite a 'constructivist' style of learning and I didn't really network very much to achieve it. James Neill helped thanks!

One of the polarities of digital communities that Wenger talks about in 'Digital Habitats' is the balance between participation and reification (or the creation of objects and artifacts). I wonder what the balance is in CCK09 at the moment. From my perspective it seems to be heavily in favour of participation as shown, for example, by the two separate discussion forums http://cck2009.ning.com/ and the 'official' http://ltc.umanitoba.ca/moodle/course/view.php?id=68. I feel that I have done more reification and not enough participating so will try and do more next week.

Wondered how connectivism is related to other theories. Having last studied learning theory about 10 years ago during a diploma in medical education I felt quite out of date. It seems everyone else has been having a deep philosophical debate about theories whilst I've been happily getting along with just applying what little I knew to OnExamination.com. So taking a lead from a posting by Siemens, and this article http://www.infed.org/biblio/b-learn.htm I put together a table of learning theories to help me fill in the blanks and see how connectivism compares. There has been a lot of talk about the differences and similarities of connectivism and connectionism which has seemed far too geeky for my liking. Might be useful to return to the table at some point and put connectionism in as well.

So, after a week I think I could say I think connectivism has far more background and argument than I had initially thought. The concept of 'emergent properties' is a bit of a challenge for me at the moment. Of what use is 'understanding' or 'knowledge' in a network if it can't be utilised by one or more of the people in the network. If it can be utilised then surely it is in the people and not the network. Hopefully we'll cover that in due course!

Reading about lifestreaming

2009-09-19T23:19:00.002+01:00

From the original definition in the 1990s as "...a time-ordered stream of documents that functions as a diary of your electronic life;" to "using lifestream data to improve memory and cognition, enhance self-awareness, and understand health".

Glossary of connectivism

2009-09-19T12:13:00.000+01:00

I've spent some time going through the suggested reading for CCK09 and making notes of the definitions of terms as used in connectivism.

http://en.wikiversity.org/wiki/Connectivism_glossary

Found this quite a useful exercise especially where it meant searching Siemens and Downes previous writings on connectivism. There doesn't seem to be much difference in the definitions of aspects of their proposed theory but they clearly have different perspectives. Stephen is more neurones, maths and philosophy whereas George is more education through social and open media. At least that's my interpretation after knowing them for a week. Enjoyed the CCK09 Elluminate discussion 17th September 2009 but didn't catch it live. Listening to the recording allowed for a more forensic approach to the posits and responses which was good fodder for several glossary entries.

However, this glossary fetish seems to be quite an individual (and obsessive) task although had help from @jtneill in the wiki etiquette. On Siemens' taxonomy of connectivism (Awareness and receptivity, Connection-forming, Contribution and involvement, Pattern recognition, Meaning-making, Praxis) I seem to have jumped the connection-forming stage and gone straight to contribution. I'll therefore focus a little more on connection-forming.

Connectivism in context

2009-09-17T13:00:00.000+01:00

Mark Smith, in his entry on learning theory¹, presents a table of 'four orientations to learning' which compares Behaviourist, Cognitivist, Humanist and Social / Situational orientations of learning theories.

This does a lot of the work of adding the aspects of 'Communities of Practice' in to George Siemens' comparison table which is something I wanted to work on.

So I have posted it as a Google Doc with some additions.

1) Smith, M. K. (1999) 'Learning theory', the encyclopedia of informal education, www.infed.org/biblio/b-learn.htm, Last update: September 03, 2009

Case-based reasoning frameworks in medicine.

2009-09-17T12:01:00.001+01:00

I'm seeing 'connectivism' everywhere now. I'm getting that feeling of the person with a hammer who sees everything as nails!

One of the authors submitting to BMJ Case Reports wonders if a large online collection of medical cases could assist patients or health services in finding the most appropriate medical care.

http://blogs.bmj.com/case-reports/2009/09/15/finding-your-doctor-through-their-published-case-reports/

RSS aggregation

2009-09-15T21:22:00.000+01:00

Have played around with a lot of different RSS aggregators now. The one that seems to work best for me is Yahoo! Pipes. Very easy to use.

Here's an aggregation of my various RSS feeds.

and here's one of CCK09 tags.

What is Connectivism? Week 1: CCK09

2009-09-15T13:52:00.000+01:00

Reading George Siemens' handout for Week 1 asking 'What is Connectivism?'

This is a good overview putting the aspects of Connectivism in terms of other learning theories. Maybe there is more to it than I initially thought! He models this on Mergel’s emphasis on Ertmer’s and Newby’s “five definitive questions to distinguish learning theory”. The original paper by Ertmer and Newby is also available as a PDF (Behaviorism, cognitivism, constructivism: comparing critical features from an instructional design perspective. Performance Improvement Quarterly 1993;6(4):50-72). The two additional features suggested by Ertmer and Newby on Schunk's original list of five were about instructional design in particular and it may be interesting to expand Siemen's list to include these. After all why exclude the instructional design aspect? CCK09 has undergone a process of instructional design.

Also I think it should include social learning theories in the comparisonsuch as 'communities of practice' which also talks of the learning that takes place in the connections between individuals and the knowledge that exists outside the individual.

CCK09 start page

2009-09-15T11:50:00.003+01:00

Not sure I fully understand what is meant by the term "personal learning environment" as defined by the connectivists (better look it up - or start a glossary as part of my course work) but found one example provided by emapey which I've borrowed and adapted.

This is a start page for the CCK09 course so that I can find all the links easily.

Week 1, Week 2

The Daily News: The Daily
Moodle LMS: Course: CCK09
Participants: CCK09: Participants
Elluminate: CCK09 Live Sessions
Elluminate: CCK09 Recorded sessions
Wiki: University of Manitoba
Wiki: at Wikiversity

Tagging makes the course easier to aggregate.

Yahoo! Pipe (of everything I can find): CCK09 tags

or, for more focussed searches ...

Google Blog Search: cck09 – Google Blog Search
Twitter CCK09: cck09 – Twitter Search
WordPress CCK09: Cck09 Blogs Posts on WordPress
Delicious Bookmarks: Recent cck09 Bookmarks on Delicious

Origins of Connectivism and review of CCK08 (#CCK09)

2009-09-15T09:19:00.001+01:00

Starting CCK09 course having caught the first part of the elluminate session last night.

Just listened to George Siemens talking about the origins of Connectivism in the dichotomy between his traditional teaching of students in a learning environment and his own personal CPD conducted in a more open and free way. In early 2000 he used blogs and other tools that would later be called 'social media'. He believes that learning is fundamentally 'networked' through contacts between people. He asks the questions "what could education be ... how can we change our teaching to reflect the reality [of connected learning]"?

http://www.youtube.com/user/gregaloha#play/user/209BAC7DAACFEDBC

In 2008 he and Stephen Downes launched an online course in 'Connectivism and Connected Knowledge' CCK08 which was designed to teach about Connectivism as a theory using the tools and activities of Connectivism as the mode of learning. This is quite a handy way of teaching learning theories which would otherwise be hopelessly abstract. The course was well received and they were encouraged to run it again as CCK09.

The tutors created a loose structure based on reading lists via email and Moodle, suggested tagging to pull together contributions, and provided a rhythm to the course. The students demonstrated great creativity in their use of emerging technologies to further explore the course content.

I am having difficulty seeing what is new here in terms of learning theory. People have always learned from each other through connections between peers. What is different is the number and asynchronous availability of these connections in the Internet era. Does this level of 'connectiveness' qualify as something different? Could it just be a tool that makes education more accessible and convenient?

Postcode mortality

2009-09-11T08:58:00.001+01:00

It seems where you live determines the deprivation and mortality rates you experience. The pattern has persisted for the last 100 years. The link between poverty and mortality is as strong now as it was then despite a century of scientific, social and political improvement. This interesting research article in the BMJ by Ian Gregory, senior lecturer in digital humanities from Lancaster, is based on analysis of Census and other national statistics data.

Gregory I. Comparisons between geographies of mortality and deprivation from the 1900s and 2001: spatial analysis of census and mortality statistics. BMJ 2009;339:b3454

Is this surprising? It's not surprising that where you live determines the sort of life and opportunities you experience. What is surprising is that those same places have not changed greatly in their relative position of deprivation and mortality measures in the last 100 years. But then you'd have to look at a longer timescale to see changes in the fortune of particular localities. Postcodes remain a good predictor of deprivation and mortality.

Seven Principles for Cultivating Communities of Practice

2009-09-09T13:58:00.002+01:00

An outline of the seven principles for cultivating communities of practice from Etienne Wenger's book.

http://hbswk.hbs.edu/archive/2855.html

From their experience they derived:

Design for evolution.
Open a dialogue between inside and outside perspectives.
Invite different levels of participation.
Develop both public and private community spaces.
Focus on value.
Combine familiarity and excitement.
Create a rhythm for the community.

The 7th 'create a rhythm for the community' is particularly relevant I feel and is something we've employed in our Diabetes Diploma course at Cardiff University - the use of weekly case problems. Rhythm maintains engagement.