Monday, 2 March 2015

Are speech and language therapists too "nice" for robust peer review on the internet?

This is a sensitive post that explores the issues around debates that take place on social media. Whereas with other blogs I have attempted to source third party information, due to the sensitive nature of the story told, parts of this blog will remain anonymous.  Some readers will be aware of specific events I have referred to from Twitter, but as the role of this blog is to explore the themes and principles necessary to learn about professional development through social media, individual names and tweets will not be repeated here.

Social media has burst into the professional arena over the past few years and is increasingly being used to network with colleagues, share information and reflect on practice.  In my last blog "Healthy skepticism in clinical practice" I recommended Twitter as a forum to share critical thinking in order to develop robust practice.   The past few days, however, have been rather heated in the Twittersphere with allegations of cyberbullying and individuals being requested not to use certain professional networking hashtags as a result of their previous tweets.

The twitterstorm originated from one user challenging a speech and language therapist who had hosted a guest post about psychological astrology on a professional blog.  Requests were made to remove this post with the argument that it did not adhere to the principles of evidence based practice.  A lively discussion followed on twitter which extended to discussion around evidence based practice and blogging in general.  Shortly after this, however, the originator found themselves the subject of allegations of cyberbullying from several users of the professional hashtag.  Allegations included using an inappropriate tone in tweets, "obsession with EBP", and fostering negativity on the hashtag.  The originator was asked by these users to stop requesting that fad therapy posts be removed, stop asking for evidence for interventions and to stop using the professional hashtag.  Whilst there may be differences in opinion over the hows and whys of the discussion that had taken place, was it necessary to jump to public allegations of cyberbullying?  And was it appropriate to request another user to stop tweeting and to veto them from a professional network hashtag?

This incident has raised a few issues that as a profession we need to explore. Discussed in more detail below they are: a; the nature of pre peer review publication, b; conduct on social media concerning peer review and c; professional standards in the world of social media.

The nature of pre peer review publication
Before the emergence of social media most professionals communicated through peer reviewed journals or edited professional magazines.  These media give should give the reader confidence that the reports and views of the author have been reviewed and given approval for publication by other professionals in the field. (That assumption has recently been in dispute in one case, as described by Bishop, but largely holds true).  Whilst professional magazines (such as the RCSLT's Bulletin) are not peer reviewed, the editorial process provides some protection to the reader against outlandish or rogue opinions.  Magazines also often give an opportunity for readers to respond to articles through a letters page.

Things on the internet are different.  Individuals may freely publish articles on blogs without any peer review.  Opinions can also be tweeted without checks and balances on twitter and can reach thousands of people very quickly.  This has benefits and disadvantages.  One of the benefits of these forms of media is the democratisation of opinions.  You don't have to be an established figure or authority to have a voice, and anyone can comment on information.  Another benefit is the speed and degree to which information can be shared amongst professionals.  Through tweets and blogs news gets out very quickly and can be disseminated widely.  I believe I am better informed in my area of practice (early language development) than I would be if I were not on Twitter and did not read other professionals' blogs.   Social media also gives an international perspective for things, so as a UK speech and language therapist I am learning from professionals in different countries and different health economies. In her keynote speech to the RCSLT 2014 conference, Caroline Bowen proposed that Twitter was useful for generation and dissemination of news, engaging in discussion, asking and answering questions, inspiring, encouraging and supporting others, participating in professional learning networks, and connecting and collaborating with groups. Disadvantages of social media, however, include the ease in which cod science and quackery can be distributed and the unpleasant interactions that can result from this unregulated environment (both of which I have alluded to above).

Two blogposts with guidance for academics on Twitter and Blogging have been written by Dorothy Bishop.  This guidance may be equally applied to clinical professions, such as speech and language therapy.  Bishop also discusses the role of blogging in post publication peer review here. The value of peer critique on social media extends beyond post publication review of peer reviewed journal articles. I would argue it is not only of huge benefit to our profession but is essential in the presence of pre-peer reviewed publications, such as professional blogs and websites.  It is the post publication review (via comments on a blog, tweets and shares) that takes place within social media that helps the wider community interpret and understand the validity of what is published.  Put simply, if you blog or tweet, you need to be open to critique of what you are saying.  If we seek to stifle or subdue opinion, that is to the detriment of our profession.

Conduct on social media concerning peer review:
Given the unregulated environment of social media, and its relative youth in terms of a medium for human communication it is not surprising that things go wrong.  There are many examples in Twitter of where things have got nasty and personal.  Trolling on Twitter happens and we need to be aware of it. There are steps you can take to protect yourself from this, including blocking and reporting offensive tweeters.  The extreme reaction to this is not to be on Twitter, or not to tweet what you really think.  Whilst I always advocate 'thinking before tweeting' and not being offensive or personal, it would be such a shame if our desire to always be 'nice' or 'positive' resulted in a muting of the debate.   Our profession could consider a code of conduct when communicating with others on Twitter.  There are several questions that such a code might address.  First, what is the right way to critically appraise someone else's work?  How might someone whistle blow if professional misconduct is observed on social media?  How should we decide what is the appropriate use of a hashtag?  I would argue that it would not be appropriate to dictate who can or cannot use hashtags as that goes against the democratic nature of social media.  It seems reasonable, however, to have explicit agreed rules over how a hashtag may be used.  #WeSpeechies, for example has a rule that the hashtag is not used for promotion or advertising of commercial goods and services.

Professional standards in the world of social media:
Another issue that this incident raised is the extent to which we are free to publish or post what we like on a professional blog or website.  A clinical standard which all speech and language therapy professional bodies now expect, for example, is adherence to the principles of evidence based practice.  Our clinical practice falls along a continuum regarding levels of underpinning evidence and I would doubt anyone would advocate too strict a policy regarding what level of evidence is required for services.  It could be argued, however, that it is not appropriate for our profession to promote services that would be considered 'rogue' or 'outlandish', however, or services where there has been clear evidence of non-effectiveness.  Given that many speech and language therapy professionals now use the internet to promote services, I suggest that our profession would benefit from professional standards on blogging and other publication on the internet.

Update 6th March:
Thank you to those of you who responded to a request for information regarding current guidelines. In the UK the RCSLT does not have its own standards, but refers all enquiries to the HCPC which has guidelines on social media here. Speech Pathology Australia have guidelines here and please see Caroline Bowen's comment below for guidance on use of the #WeSpeechies hashtag. If you are aware of any other professional bodies across the world with guidelines or standards for publishing on the internet, please do get in touch with me and I'll update this blogpost.

Conclusion - are we too nice?
The internet is the 'wild west' of our professional practice.  Currently unregulated and with no code of conduct it appears that anything goes.  This can be refreshing and liberating but it also has its consequences.  While we do develop our practice in this arena, however, I challenge the reader to consider the priorities. When working towards a better, more clinically robust service for the benefit of our clients (who I would hope should always be the priority), let's not close down discussions for fear of not being 'nice' enough.  We need to be robust and stand up to critique, especially those of us who publish on the internet.  Try to be nice on the internet, but not too nice not to keep the debate open for the benefit of everyone.

3rd March 2015 PS: Further to my request for information on guidelines from different professional bodies I have received comments from readers with information.  I am waiting to hear from others, after which I will update this blogpost.  In the meantime please do read the comments below where you will find more information on professional guidelines for social media and internet use.

13 comments:

  1. That is very constructive and very eloquently expressed. I do hope that your reflections, and your action in contacting RCSLT for advice, help to move things forward.

    It is worth mentioning that the HCPC, as the body regulating Health and Social Work professions in the UK, has already issued some general "social media guidance" that applies to UK Speech and Language Therapists.

    I imagine similar guidance will have been issued by the bodies responsible for regulating standards of professional conduct and ethics in other countries.

    For information, the HCPC guidance, which places social media in the context of its General Standards of Conduct, Performance and Ethics, can be downloaded here:
    http://www.hcpc-uk.org/Assets/documents/100035B7Social_media_guidance.pdf

    Thank you again for your very thoughtful and positive response to the

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    1. Thank you very much Liz for highlighting this guidance from HCPC. I have also heard from Caroline Bowen, Speech Pathology Australia also have some guidance. I am waiting to hear from RCSLT and any other professional bodies and I will update the blog in a week or so. In the meantime I'll add a postscript directing readers to your comments. Thanks once again, Clare.

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  2. Wonderful post, clear-thinking Clare! Thank you.

    These are Speech Pathology Australia’s Social Media Guidelines:
    http://www.speechpathologyaustralia.org.au/library/M_and_CO/SpeechPathology_and_SocialMedia.pdf

    In my view SLP's/SLT's conduct in social media must ultimately be governed by our Codes of Ethics and Standards of Practice (or whatever they are called in the part of the world readers here are from), taking into account the particular pitfalls of micro-blogging. Twitter, in its possibly little-read Terms of Service does its part by providing this: https://twitter.com/tos?lang=en to guide all Twitter users.

    In developing the @WeSpeechies' Guidelines for Curators, the Administrators Bronwyn Hemsley and I have never felt the need to advise RoCurs how to behave nicely in Twitter. However, to protect us and protect them if necessary we round off the 3-page document with this request:

    'Curators are requested to follow the Twitter terms of service (https://twitter.com/tos), just as they would with their own accounts. While curating, you are responsible for the image you present and the content you Tweet. The @WeSpeechies administrators reserve the right to warn and/or revoke the access, of anyone who violates Twitter’s terms of service or engages in ableism, ageism, homophobia, racism, sexism and the like while tweeting from the account.'

    Congratulations on Blogsmith, Clare.

    Caroline Bowen

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    1. Thank you Caroline for your comments and for highlighting both Speech Pathology Australia's guidelines and your guidelines for @WeSpeechies. I have also heard from Liz Panton with guidelines from the HCPC. I plan to update the blog in a week or so when I may have heard from others. In the meantime I'll add a postscript to the blog alerting the reader to your comments.

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  3. Thanks for raising this important issue. I'm not a member of the SALT/SLP profession but I work closely with SALTs and value the important role they play. I think you are absolutely right that the national organisations for this professional group urgently need to introduce some guidelines regarding social media, for exactly the reasons you articulate. In particular, they need to show a commitment to evidence-based practice, without which the profession loses all credibility.

    To add my own perspective as an observer of the profession, I am concerned that it has become academically weaker over the 40 odd years I've worked with SALTs. In the past, and still in many centres, it attracts some of the most academically able students, who are selected for combining clinical skills with an aptitude for understanding the diverse range of topics that are required: linguistics, psychology, anatomy, and neurology. In some courses, research methods and statistics are a specific focus, and I'd argue this is crucial if the profession is to survive. Without a scientifically credible evidence base, there is a danger that SALT will lurch in the direction of complementary and alternative medicine, embracing various untested and at times crackpot therapies, as in the recent case where 'psychological astrology' was advocated for communication problems. This would be disastrous for clients, who imagine that they are being seen by trained professionals who are drawing on an established knowledge base. It could also be disastrous for the profession itself: in the UK, SALT could disappear from the National Health Service in times of stringency if it is not willing to provide evidence for its own practices. As the blogpost points out, the argument is not that one cannot offer only those interventions that have been tested in randomized controlled trials. But the therapist should behave like a practitioner scientist, adopting a hypothesis-testing approach to designing and evaluating interventions, based on knowledge of linguistics, psychology and neuroscience.

    I think you're right that sometimes SALTs can be too nice, in the sense that they don't like to get into situations where there are differences of opinion. But unless the professional bodies take a strong stand on what it means to be a SALT, then the whole profession will suffer.

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    1. I have removed this comment as it identified someone involved in the original incident. As I mentioned above, this is a sensitive issue and the purpose of the blog was to explore themes and principles involved in critique on the internet. I welcome critique of the blog and the commenter is invited to comment again but I politely request that people are not named.

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  7. Thank you for your blogpost, Clare. I think it opens up a timely dialogue about some of the issues that have been swirling around social media in the past weeks. To position myself firstly, I fully support the use of social media to promote evidence and the translation of this to practice, and agree that the SLP/T profession should be identifying and talking about fad interventions, the impact of these, and alternative (evidence based) pathways to support clients.
    At risk of going out on a limb, it’s been interesting to me that much of the ‘response’ since the discussions last weekend has largely come from researchers – those considered by the field as experts. Clinicians, whilst being involved in the initial outburst, have been less prepared to put any further thoughts or reactions into the public domain. I wonder if this lack of voice reflects some of the concerns that were voiced by ‘the group’ you refer to.
    We know from research about evidence translation that it’s not black and white. For clinicians, service delivery is messy and clients are heterogeneous. Their decisions about how best to suit their needs are influenced by their knowledge and access to evidence, absolutely, but also by the desires and goals of clients, their own professional identity and experience, and socio-cultural factors among others. For clinicians, social media may provide a place to not only access information, but also to explore their practice, to contextualise their problems, and to find social and professional support.
    I have been watching interactions on social media for some time now, and whilst last weeks’ events could be construed as related directly to the callout of a fad intervention, my feeling is that the issues that emerged were also from a much broader context than the need to promote and digest evidence. I have been increasingly concerned about the divide between researchers (experts) and practicing clinicians in the social media space, and feel that the gulf may be widening (and yes, I feel that I also perpetuate this divide). This is not a generalisation – of course there are still a number of clinicians engaging regularly in conversations with academics/researchers. However, without careful consideration, I wonder if we run the risk of researchers communicating largely with other researchers (experts talking with experts) in social media, whilst those we hope to engage are either avoiding conversations or disengaging from social media altogether. I feel this is occurring in Twitter at the moment. If we are looking to use social media as a means to encourage the translation of evidence, we need to think about doing this in a way that engages all parties who might be interested in conversing and learning.
    I think the voice of non academic people, practicing clinicians, and clients is crucial here to open up a discussion about any underpinning concerns. From my observations, I wonder how safe people feel to have conversations about their practice; whether they feel ok to talk about scenarios where perhaps the grey nature of the clinical context results in them working in a way that doesn’t directly reflect the best evidence (this happens often); and whether they feel able to have the organic conversations about messy practice that occur verbally between colleagues, in a social media space. I wonder whether our drive to strongly promote evidence through engaging in social media (which is important) may have the unintended consequence of shutting the very people it’s intended for out of the conversation. What I’m not suggesting is that we shouldn’t be talking about evidence. I do wonder though if we need to be sensitive to the differing cultures of academic and clinical practice, perceived power differences, and be monitoring engagement from our interactions. We also need to hear clinicians’ voices; to be talking with people, not at them.

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    1. Thank you Stacie for your thoughtful comments. First, let me position myself in this debate. I am a clinician and a researcher, and have been fortunate enough to receive a grant from the NIHR to complete a clinical doctoral fellowship, part of a trainee programme to actively promote the bringing together of clinical practice and research. Your comments raise a very important issue, which is all about bridging the gap between the clinical and academic arena. It is worth noting that there are many academics who are clinically active and many clinicians that, whilst they don't consider themselves to be academics, are actively involved in research. It is this joined up working that we all need to foster and encourage and I actually believe social media environments such as Twitter can support this. I also understand your comments about clinicians who have not been actively involved in research or postgraduate academic programmes perhaps finding the discourse that sometimes happens on Twitter overwhelming or intimidating. My PhD journey has begun to teach me how to cope with critique and academic clinicians and researchers are perhaps more comfortable with this. It would be interesting to explore the views of clinicians regarding these debates in order to enable us all in having an inclusive and robust discourse regarding evidence based practice. If, as you suggest, people not involved in the research element of evidence based practice are reluctant to engage in the date, this is something that, as a profession, we shy away from at our peril. First, every registered clinician is guided by the standards of evidence-based practice and their voice is important in the debate. It is absolutely appropriate to highlight clinician expertise and consensus and client views and experience as part of the evidence base. Second, the health economy (particularly here in the UK) has become increasingly more competitive and we (rightly, I believe) are being asked for evidence underpinning our practice by our commissioners. Services that are not underpinned by evidence risk being decommissioned. Our profession is much more robust if we can back up our practice with the 3 elements of evidence based practice, and the clinician voice is essential to contribute to this. There is therefore, no place for separate academic and clinical camps as both voices are valuable. I would like to reflect the voices of others on Twitter in suggesting that when we consider the best practice for our clients, there should be no researcher/clinician 'them' and 'us', just an 'us'.

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