Death and suicide on the web

A friend pointed me to an article (found via a post at Think Christian) titled, "The Web Is The Worst Place to Grieve." The article, published in a conservative-libertarian magazine, describes several examples of real and feigned suicides that have been blogged on the web.   Blogging had made possible public suicide notes.  The article is a good reminder of the dark side of Web 2.0 whose opportunities and possibilities I've explored here in the past (see posts in Blogging category).

eMJA: The effect of Web 2.0 on the future of medical practice and education: Darwikinian evolution or folksonomic revolution?

More blogging to come at URMC?

I was invited to an informal, coffee-cart conversation about blogging in a medical center.  A person in our organization wants to develop a group blog around the interest area of Community Health.

A few reflections on this conversation, which took place on Friday.

  1. We spent a fair amount of time on definitional ambiguities around the word "blog." I had never realized that the word can evoke lots of different images in people's minds. At different points, it morphed between meaning "anything RSS," "Web 2.0," "collaborative Internet", and "discussion board." That happens with any word (I say "chair" and think of this and you might think of this), but it is especially true of word describing emerging concepts.

  2. I became aware of how personal my blog is to me, and how much I resist efforts to legislate aspects of it. I didn't like ideas that entailed requiring people to commit to post once a week or something like that.  I'm sure corporate blogs do something like that, but for a blog that is about idea development, I think the frequency should match the idea generation and can't be forced.

  3. I had never thought before about how to get "buy-in" from people to blog. My recommendations to those involved in this project was that the only way to cultivate bloggers is to get people reading blogs first. Get them understanding RSS and some of the benefits to blogging (including in clinical or academic communities) from a reader's standpoint. I think it's hard to imagine why spending time writing posts would be useful to oneself or others until you've seen it in action.

  4. My other thought about "buy in" is that you have show people how any project that will require time and effort will promote their careers, not just promote a concept.  For faculty, it's about intellectual development.  You'd have to show and provide examples of how writing thoughts that are still under-development to a wide audience can be helpful.

  5. I found myself thinking a lot about (and mentioning to my colleagues in our discussion) the Merlin Mann's quote that I have referenced here before, in which he describes a blog as "only incidentally a publishing system...At its heart, your blog represents the evolving expression of your most passionately held ideas..."

  6. Web 2.0 is all the rage right now.  Articles like this one in InfoWorld talk about the growth of vendors who are trying to profit from this. There are a lot of ways leaders can go wrong when trying to jump on the Web 2.0 bandwagon. These 23 steps for learning Web 2.0 have gotten a lot of attention lately. Seems like a thoughtful approach, perhaps a prerequisite "course" for anyone interested in how a particular institution might benefit from the new web.

  7. It's important to consider which tool is right for which purpose. Blogs are great for pushing content to interested audiences, wikis for collaboration on specific projects, etc. When is it best to use multiple individual blogs and when is it better (as I think they're going to try here) to have one blog with multiple contributors?  My personal preference as a consumer is for the individual blog because part of my interest is watching the creative process take shape in an individual over time.  But maybe that's just the clinician in me.


It was fun to be part of the discussion at this early stage.  I'm excited to see where the initiative goes.

Example of risk map

In a comment on my previous post about visual presentation for clinical training in risk assessment, Avi of GUI Yourself requested an example. Here is a .pdf of a map I use. The details are collapsed, but you can get the idea.  I also teach using a map of the options available to clinicians in our system.  I am working to customize that map for each service area I train (with the aim of influencing implementation and transfer, as discussed in this post).

Evidence for visually different presentation format

The materials I am working on to train clinicians in risk assessment involve visual maps which I present using Mindmanager. I have blogged about this learning tool before (here and here). Well...I haven't read the source research that this article from the Sidney Morning Herald is based on, but it looks like it provides data to back up the contention that people learn best by being presented visual stimuli that complement and enrich what the presenter is saying, rather than repeating or rewording it like many Powerpoint presentations or other handouts do.

Tip of the hat to LifeDev, where I first learned about this article.

Reflecting on Intersections with Knowledge Management, Dave Snowden, and Singapore’s Risk Assessment and Horizon Scanning System

Warning: This post starts out a bit far afield from clinical work. My ideas about how it ultimately connect back, but they're still forming, so this is definitely a "put on your seatbelt" kind of post.

For some time, I have been following the work and blog of Dave Snowden, founder of Cognitive Edge. Snowden is an scientist, theorist, and organizational consultant at the cutting edge of the Knowledge Management (KM) field. Or perhaps it would be more accurate to say that Snowden is a pioneer and visionary who is try to push KM to an entirely different dimension (call it KM 2.0). I must admit that I am still trying to get a handle on Snowden's thinking (it's broader and more complex than I can yet grasp), but one of the most interesting things to me about his work is that he emphasizes narrative (versus purely numerical) approach to "sensemaking." Snowden and others of his ilk argue that you can learn more useful information, detect more weak signals, capture trends earlier through gathering stories than you can by gathering numbers. Stories show emerging trends. Numbers tell you what has already happened.   (For a popular version of this argument see Lori Silverman's provocatively titled book "Wake me up when the data are over: How Organizations Use Stories to Drive Results")

Snowden and another KM guru, Gary Klein, were recently videotaped discussing the methodology (and software) that the Government of Singapore has developed to help them detect terrorist risk, the Risk Assessment and Horizon Scanning (RAHS) system. I found their videotaped discussion fascinating, especially Snowden's critique on the failures of knowledge management (2nd clip on the page). I don't know enough to understand the differences between the perspectives Klein and Snowden offer (and, can't in fact follow all of what either one says), but I listened with great interest to their perspective on how one approaches information-gathering, sensemaking, and decision-making in an uncertain, unpredictable, and unstable environment.

Obviously, clinical sensemaking and decision-making is quite different from government counter-terrorism operations. But I could not help but think of parallels, especially for assessment of suicide risk. Here are a couple of developing (and somewhat random) reflections I had:

  1. We know about statistical risk factors, but how do we do sensemaking with a particular person's set of stories. Clinicians have access to rich narratives, but we generally lack methodologies and technologies for sensemaking that retains complexity and guides decision making.

  2. Traditional documentation (the principal knowledge management system for clinical care), including the diagnostic evaluation reports, usually flatten the richness of stories (by design) into a language that is more technical, linear, and sterile than real life. We usually don't capture stories on their own or track raw data, but rather we move quickly to interpretation and synthesis.

  3. I noted in a previous post that I use mindmapping to teach about suicide risk. In that post, I suggested one benefit might be "it helps to be able to visualize connections between concepts on a map because it makes complex material more accessible." In light of what I'm learning from Snowden and KM, I wonder if mindmapping also facilitates sensemaking from narratives better because it is nonlinear and attempts to replicate connections in human thought patterns.

  4. Apropos of my previous post, Where's the family?...family therapy offers an opportunity for gathering anecdotes from multiple perspectives. Snowden has a KM exercise called "Anecdote Circles," which he uses to help organizations gather information through story. The techniques he uses would be interesting to apply to a family, and to gathering information from family members about suicide risk. This kind of raw data is not available without family members.

  5. Our models and language around risk assessment needs to better reflect how fluid and unstable the phenomena of risk and suicidality really are. The act of suicide is a momentary coalescing of a multitude of snippets and anecdotes and narratives. Reading retrospective case studies of people who died by suicide makes that really clear--all of what we categorize as "risk" comes together in a certain way at a certain point in time. As one of my mentors pointed out to me last week, we can "predict" suicide retrospectively, but it is almost impossible to detect prospectively.  As clinicians we want to be sensitive to the snippets, so that we can scan the horizon (a la RAHS) and sense emerging trends, far before the data ever catches up.


As I warned in the beginning, these thoughts are pretty raw, but I'm interested in exploring this intersection more.

Blogging out in the open in a clinical setting

Roy from Shrink Rap’s commented on my post about Web 2.0 opportunities that he has "not EVEN mentioned to anyone about our psychiatry podcast." That surprised me, given how significant his web presence is. But that was certainly true of my blog until a couple of weeks ago, when I finally "decloaked" my blog to my colleagues.

I decloaked during a presentation to our group that focuses on evidence-based practice. This group includes several key leaders in our department. I was giving a progress update about my work toward our shared goal of improving the training and documentation tools for suicide risk assessment, documentation, and response. Thankfully, the project is progressing, and I had several steps forward to present. On the mindmap I was using to present, (as I've noted in a previous post, I use MindManager for presentationg), I reported progress on steps forward that I had previously committed to, then added a bubble reporting the development of this blog (along with a link to it).


I introduced it with some trepidation. By way of disclaimer, I started by recognizing that the image some think of when they hear the word "blog" (if they think of anything) is a "navel-gazing, exhibitionist teenager" sharing stories about weekend parties and rants about parents. I explained that blogs have evolved in many professional and academic circles as a way of journaling ideas and sharing emerging trends with like-minded people. I showed some sample posts and sample comments. I referred people to the About this blog page if they wanted to learn more about what I'm up to with this experiment.


The response was mostly positive--probably best described as a mixture of amusement and curiosity. No one was openly critical, and some of my colleagues thought it was pretty cool. There was one appropriate and constructive question raised about liability issues for me (what if someone follows my clinical advice and something goes wrong), but no other public comments. One colleague later comment that she had never read a blog before, and I suspect that was true for many people in the room.


Being out in the open feels good, although it has already changed the way I think about my blog. I don't think the change is good or bad, but it does change my mindset to think that my colleagues and superiors might read what I write here. Then again, they might not!

How clinicians learn: Web 2.0 Opportunities?

A thoughtful colleague of mine observed yesterday that, although there is a range of ways clinicians get clinical information about suicide (articles, workshops, books, practice manuals), a lot of clinical learning takes place informally--by doing the work and by talking with other clinicians. That is probably especially true for the busiest front-line clinicians.

I later reflected about what this could mean in terms of Web 2.0 opportunities to change clinician behavior. First, the narrative, personal feel of blogs might appeal to clinicians in a way that practice manuals and official websites don't.   Second, the conversational opportunities of wiki (Wiki in wikipedia, Using Wiki in Education), RSS feeds, podcasts, and other Web 2.0 venues also have potential to reach people in a fresh way.

Would a front-line clinician who does not regularly read research journals subscribe to a weekly 10 minute podcast conversation between a suicide researcher and a clinician who works with high-risk patients? Maybe. It's mostly an empirical question at this point, but there are several experiments going on in the field, some of which are on my blogroll.

Tech tools for clinical thinking and training

Whenever I present, I get questions about the technology I use. I work on a Fujitsu T Series Lifebook (T is for Tablet PC), and use MindManger by Mindjet for almost everything I think about or present. I'm happy to let people know what I use because I think they are tools that lend themselves well to the clinical enterprise.

I like using a Tablet for presenting or for taking notes when meeting with families because it sits in front of my like a pad of paper. For some reason, I am also able to listen better when I'm only working with one hand on a computer. It's hard for me to listen, write, and engage when I'm using both hands on a keyboard.

I first learned about MindMapping from a classic book on the subject by Tony Buzon. I use it for brainstorming, project management, and presenting. I'm still in the process of investigating the relationship between visual maps (mind-mapping or concept mapping) and learning complex concepts. I've done a partial lit review about it in the educational literature and it seems like there are a lot of theories (and, of course, few data) about why visual maps would promote learning different from plain text. For suicide risk, I think it helps to be able to visualize connections between concepts on a map because it makes complex material more accessible. I have a map of risk factors to consider that somehow enlivens discussion of something that could feel quite rote or overwhelming.

It may be that these tools are also effective because they haven't yet (and I mean yet) become mainstream. People are intrigued because they are different. I'm OK with that, but I hope that's not the only factor at play.