Monday, 6 May 2013

Who is your audience? - Learning about burnout through social media

Rock Audience

Image : Rock Audience by Peter Bongard

"The Rules"

Last week a new website appeared : The Moderate Doctor. The purpose of the website was to host "The Rules", which were originally described  as follows
 "The Rules have been developed to help patients maximise their experience of consulting a GP, and give GPs a chance to vent their frustration at the sometimes bewildering world of the consultation. For anyone of a sensitive disposition-do take The Rules seriously! I hope everyone can find some therapeutic benefit in them-doctors and patients alike."

So from the start The Moderate Doctor was pretty clear that this was meant to be satire, although I did suggest to him that he removed any suggestion that these would help patients because I didn't think that it would. And he did. However, less than a week after publishing the rules are gone from the website. Dr Moderate has said the he meant this as some fun but that it wasn't worth the 'vitriol' and 'grief' which he had received and the he could do without the 'GMC imitators'. Personally, I do not think that the GMC would be interested in this blog or twitter account and if someone thinks that they would, it probably means that they don't understand the guidance on social media. Dr Moderate was not breaking any confidentialities, or doing anything else that I think is in conflict with Good Medical Practice.


So what audience was Dr Moderate aiming for? He is a keen cyclist and he had based the his rules on The Rules published on the Velominati's website. Who are the Velominati? They are' cycling disciples of the highest order" who spend their days "pouring over the very essence of what makes ours such a special sport and how that essence fits into cycling’s colorful fabric".Their website is for those who are DEDICATED to cycling. Their rules might not make that much sense to the rest of us but it is pretty clear that the rules are aimed at those who consider themselves as Velominati, and only those. There is satire but they are laughing at themselves and their own healthy obsession. 

Dr Moderate was trying to achieve something much more difficult. His rules were not aimed at making fun of  a set of super dedicated GPs, but seemed to be aimed at bonding with other doctors through joking about their patients. It wasn't clear that the focus of the joke was the doctor. That made some people feel uncomfortable. One member of the public wrote replies to the rules in his own document as he couldn't fit them all into the comments. In general there was quite a lot of confusion about who the rules and the satire was aimed at.... 
When doctors quibbled about the rules they were often called into question the content not the tone of them. For example, this London GP replying on Dr. Rant's Facebook page suggests that for patients to bring lists is very useful as often problems are related. And a patient complaining of tiredness could have a serious condition so shouldn't be dismissed. I am certain that  if the list had stayed up we could have had very interesting conversations about many of the ideas that they raised. But it's clear that Dr Moderate was reaching a more diverse audience with The Rules than he was expecting.

Do The Rules raise bigger questions?

There is much talk of GP burnout at the moment. If you are a UK GP can take a survey on the Pulse website  to assess how you score for measures of emotional exhaustion, depersonalisation, and lack of personal accomplishment which are recognised features of burnout. Clare Gerada writes in Pulse that "‘Everything else has increased our workload. The insistence that perfectly healthy people “see their GP” hauls demand for access to an unreasonable level and casts us in a role that we have never asked for." One of the doctors who is sad at the withdrawal of the rules mentions that it was good to know that there were other doctors who felt the same about abuse of the service. So it seems that increased workload may be behind The Rules and behind the concerns about GP burnout.

Is workload related to burnout? A study of medical students who applied to medicine in 1990 (McManus, Keely and Paise, 2004)   measured personality traits and approaches to learning at baseline, and then followed them up in their final year or medical school, their PRHO year and again a few years later. They found the personality and learning style at baseline, predicted feelings of burnout at graduation and approach to work 5 years later. Medical students who were more extravert, had a deeper approach to learning, were less neurotic, and more agreeable were less likely to report burnout, stress and exhaustion later, and then a more positive attitude to work and a greater sense of accomplishment later still. So does personality lead to stress and burnout which then leads to work dissatisfaction rather than the other way round?

But there is some confusion about burnout too. How important is it?  Does it affect the way that doctors practice or communicate? Two studies suggest that it might not. A study in the US by Ratanwongsa et al (2008) measured burnout in primary care doctors and then taped consultations with patients, assessed them against the ROTER scale  and measured patient satisfaction. Burnout was correlated with patients saying more negative things as an attempt to build rapport, but otherwise there was no correlation with patient satisfaction. And in the UK a cross-sectional study of GPs by Orton et al (2012) found high levels of burnout, but when consultations with patients were examined the burnout was not obvious to observers, and there was no correlation with patient satisfaction. So when the results of the Pulse survey are announced we will need to ask what the significance is.

Where can doctors tell their stories?

Cole and Carlin (2009) write in the Lancet, that burnout is "also a euphemism for what many physicians experience as a crisis of meaning and identity". One of the solutions is for doctors to be able to tell their stories and to be compassionately and non-judgementally listened to. Can social media have a role in this? Jonny Tomlinson's blog is probably one of the most potent examples of this. His latest post is on the impact that loneliness can have on patients and how they present to their doctors. Last year he moved many people, including me, with his post on how medicine, and we doctors. might make our patients feel shame. But his blog is only one place that he can tell his story. He has written about how he still meets every three weeks with a group of GPs who he trained with 11 years ago.

But social media is not somewhere that one can be guaranteed that one will be listened to compassionately and non-judgementally. Dr Moderate took quite a risk when he decided to share The Rules with the world. He has raised important issues and I do hope that we get the chance to explore them meaningfully. But at the same time I wouldn't blame him for wanting to avoid this space. I'll admit that my first reaction to his setting up a website to support one publication, which seemed to be based around a humourous denigration of patients, was not one of empathy or compassion. But perhaps it should have been.

Cole, T., & Carlin, N. (2009). The suffering of physicians The Lancet, 374 (9699), 1414-1415 DOI: 10.1016/S0140-6736(09)61851-1
McManus IC, Keeling A, & Paice E (2004). Stress, burnout and doctors' attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC medicine, 2 PMID: 15317650
Orton, P., Orton, C., & Pereira Gray, D. (2012). Depersonalised doctors: a cross-sectional study of 564 doctors, 760 consultations and 1876 patient reports in UK general practice BMJ Open, 2 (1) DOI: 10.1136/bmjopen-2011-000274
Ratanawongsa, N., Roter, D., Beach, M., Laird, S., Larson, S., Carson, K., & Cooper, L. (2008). Physician Burnout and Patient-Physician Communication During Primary Care Encounters Journal of General Internal Medicine, 23 (10), 1581-1588 DOI: 10.1007/s11606-008-0702-1

Saturday, 4 May 2013

Balancing personal and professional presence in social media.

During the week I was talking to some of the doc2doc team and they asked me what I thought about the GMC guidance on social media.

I think that the guidance is good in that it states that the use of social media can very positive and worthwhile for any doctor. I think that it is likely to increase engagement with social media for doctors, and through that provide many opportunities for learning. It doesn't provide guidance on some of the issues which I think are important, for example, what responsibilities does a doctor have before encouraging patients to engage in a social media space. We will have to wait for future iterations to deal with these scenarios.
But within the twittersphere and blogosphere the reaction has been dominated by controversy over the  statement that "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name."
I still hear people talking about the guidance being impossible to operationalise because how will the GMC identify these pseudonymous doctors? But why would they be trying to? No one would know if that person was really a doctor or not. The GMC have clearly said that the guidance does not "change the threshold for investigating concerns about a doctor's fitness to practice". This means that being anonymous/pseudonymous will never be an issue in itself. But if it was established that a doctor was for example bullying a colleague, or breaking patient confidentiality, then the fact that they were doing this without revealing their identity might be seen as being an aggravating factor.
Some people say that the guidance can't protect the public from charlatans who represent themselves as doctors when they are not. Well, in a way it does. If it is good practice to identify yourself then we can tell the public that they should not trust the authority of any one who represents themselves as a doctor, but  does not identify themselves, and then tries to give them advice.

When I tweeted the link to this interview earlier, Phil replied

Is it possible to separate medical and personal presence on Twitter? Why would you want to? Are doctors concerned that their personal interests or feelings will affect their relationships with colleagues or patients? If so then they may wish to try and separate our these different parts of their identity by setting up more than one account. But personally  I'm happy enough to tweet about going to a gig from my @amcunningham twitter account. Why would or could a tweet like the one that follows be an issue?

A few weeks ago I was asked to write a few paragraphs on how I think about how I present myself online for this ebook on "Social Media and Mental Health Practice".

How do I present myself online?

I first started using social media because I wanted to network so that I could do my job in medical education better. Yes, I am also a GP but I did not see social media as something that would help me to be a better doctor. I’m still not sure that it does, although I certainly do not think that it makes me a worse one. But I am very aware that most of what I say and do within social media is public. I want it to be that way. I do not aim what I say at my patients (or students) but I’m aware that they might read it, and I do not want them to be shocked or upset or worried by anything that they see me write. I aim to be professional, and I aim to respect professional boundaries.

When I am in the consulting room I reveal very little personal information. I doubt that patients are really interested. They walk in to see me and want and need to talk about them, not me. They often politely ask how I am. If I’m running late, I might smile and say, ‘Busy!’ But I would not share my own personal woes and worries with a patient. It would be wrong for me to burden them with my personal concerns. Of course, if they ask did I enjoy my holiday we might chat briefly about that. I don’t close down these conversations but I would never initiate talk about myself.

I share very little personal information online. I do not usually talk about my friends or family publicly online, and this is often to protect their privacy. However, this year I am sharing a photo that I take every day. In some ways this often reveals more personal information about me that what I write. It is something that I am aware of but rarely feel constrained by. I think that in many ways I am quite a private person, so this maybe more than being ‘professional’ defines how I am online.

Of course I might share some difficulties online, for example struggling to make technology work just the way I want it to! I don’t think that is a problem. It shows a different side of me and it is unlikely to impact in any way on the professional relationships which are important to me.I have thought about how I present myself online over the years. I try to be calm, collected, honest and independent. I hope that I come across as I do when I am offline. I am proud that when I meet people offline, who have first known me through social media, they often say that they feel as if they know me already. I would be unhappy if my online presence was considered inauthentic, so this pleases me.

 How do you manage the boundaries between personal and professional? What are the issues for you?