Social learning means better cancer diagnosis

Jacky Law spoke to Dr James Quekett about how peer-to-peer learning in physician communities is saving lives by reducing misdiagnosis in cancer.

American philosopher and educational reformer John Dewey once said "education is not an affair of telling and being told, but an active and constructive process". Social learning on the web, whereby people in trusted communities learn from each other, is a modern-day example of education as an 'active and constructive process'. And it is finding unique application in medicine.

Dr James Quekett, a part-time GP and director of primary care for M3 EU's physician community, explains that there are two kinds of social learning.

Unstructured social learning

Spontaneous social learning is a form of learning that focuses on real-life problem solving. This would typically involve a doctor presenting a clinical case in one of the therapeutic forums and asking for comment or help in finding a solution. "Essentially, this is peer-to-peer learning rather than an expert lecturing you on a topic," he says. "One of the problems with experts is a phenomenon called the curse of knowledge, where it is increasingly difficult for those experts to put themselves in the position of someone with lesser knowledge."

Dr Quekett talks about the different kinds of learning within this unstructured world. One is: "I've got a patient with this problem; can you help me solve it?" The other is: "I've just encountered this and we can all learn from it". The latter is more directed and might be information members need to know, such as the failure of a type of equipment on which lives depend, for example a component of an anaesthetic machine. It is not only clinical conundrums that are posted.

"When patients present with various conditions it can be difficult to know which route to take. Increasing breathlessness in someone with asthma, for example, may be caused by the asthma. However, I recently had a case where the patient also had muscular pains and was looking pale. On direct questioning he said the shortness of breath was unlike his 'normal' asthma. This suggested anaemia rather than asthma but this had been missed at an earlier review with another clinician. These are the kind of things being discussed and the people who take part tend to not only learn but also to become more curious.

"Changes in the NHS, which are felt to be top-down and not based on the realities, are resisted strongly"

"In general, if you look at behavioural change models, you are more likely to change your behaviour based on your peer group rather than because someone in authority is telling you to do so. Doctors are no different in this regard and it is perhaps one of the reasons that changes in the NHS, which are felt to be top-down and not based on the realities, are resisted strongly."

Structured social learning

The most important aspect for the structured forms of social learning is that there needs to be an assessment of where there are important gaps in the knowledge or attitudes of the audience.

Identifying knowledge gaps

There are subjective and objective routes to identifying knowledge gaps. An example of the subjective approach involves talking to a group of consultants in a specific area and asking them what knowledge might be of benefit for the GPs to help improve referrals. The GPs can also be asked in which areas they feel that their knowledge might be improved.

The second part of this process is then to objectively measure knowledge in a specified area using online tools such as multiple-choice questions or knowledge tests.

"The focus is therefore to get to the so-called 'unknown unknowns' by a combination of subjective and objective approaches, the latter being via quizzes and multiple-choice tests to tease out common gaps in working knowledge," says Dr Quekett.

Solving the unknown unknowns

Once the gaps are known, an established expert is invited to compile what is needed to fill those gaps, which can then be translated, with the help of a doctor within the target peer group, into a social learning format. "It is about translating what the experts say into a format that the majority of doctors can understand," says Dr Quekett. "Many experts tend to talk in a language that may not be suited to the audience as they may have a different perspective, making it difficult for them to understand how the audience perceives that problem."

There are many formats that can be deployed based on the learning need. Sometimes a simple, concise article or guideline review may suffice but, in cases where examination is required, a video may be invaluable. If this learning comes from a peer who understands the perspective of the target audience it is often more interesting. If it is also backed up with discussion around the content, the peer group can feed back and further improve the content to make it even more applicable.

Addressing cancer misdiagnosis

A good example of the value of structured social learning comes from the early diagnosis of cancer campaign. Knowledge gaps around early signs of cancer can have significant consequences and there have been high-profile examples in the media with calls for doctors to be struck off. The issue is that this problem is rarely simple.

After discussing the early diagnosis issues with Dr Quekett, Cancer Research UK sponsored a programme with M3's UK community that aimed to identify the important knowledge gaps and use social-learning techniques to improve the earlier identification of potential cases.

"This was about creating the tools to help them rather than chastising or criticising them"

"No doctor wants to miss cancer so this was about creating the tools to help them, rather than chastising or criticising them," explains Dr Quekett. "The programme was developed entirely around identifying doctors' knowledge of symptoms, the results of which were then analysed and processed into short, relevant messages that were delivered back into the community."

In the lung cancer arm, for example, primary care doctors were given six diagnostic clues that they should look for. These had been compiled by clinical research and some, such as chest pain, were less well known than others, such as cough. Since chest pain tends not to be a presenting condition in lung cancer, the hope is that knowledge of its implications will prompt the doctor to ask questions of at-risk patients and therefore be likely to send a swift referral.

In an analysis of the extent to which the messages on lung cancer were recalled by the GP community, 97 per cent said they recalled the importance of unexplained chest pain and 77 per cent that they expected to increase their rate of referral.

Structured learning is still in its infancy. The main limitation to its growth is that no-one knows the unknown unknowns. In cancer, people are aware they exist because of their consequences. Such drivers may be less pronounced in other disease areas. But that doesn't mean there aren't simple targeted messages that can bring significant improvements in care. But it may be that the real value of social learning lies in encouraging a different approach to learning, one that is about sharing experiences and, as a result, becoming more curious, more communicative and, it is hoped, better able to help one's patients.

About the interviewee:

Dr James Quekett is director for primary care at M3 EU. He qualified from Bristol University medical school in 1994, becoming a General Practitioner in 2000. Over the past 14 years he has been involved with the development of eLearning, initially as an author, before joining the team at Doctors.net.uk in 2008. He remains a working GP in Gloucestershire and is also a GP appraiser looking at the continuing professional development (CPD) needs of qualified GPs. He is passionate about the pivotal role that primary care plays in the delivery of healthcare within the NHS.

Dr Quekett is presenting a free-to-attend webinar on the value of social learning for doctors on 22 July at 9.30am. The event is designed to inform and offer expert resource on this emerging educational trend – and will deliver a case study showing how peer-to-peer learning through social media in physician communities is saving lives by reducing misdiagnosis in cancer. Click to register and attend: