GPs in Cyberspace The Sociology of A Virtual Community

GPs in cyberspace: the sociology of a
virtual community
Nick Fox and Chris Roberts
Abstract
It has been argued that on-line networked communication can enable the
establishment of virtual communities. Empirical data from an elec-
tronic discussion group for general medical practitioners (GPs) are used
to evaluate these claims, and to explore the similarities and discrepancies
between on-line and face-to-face interactions.
A distinct social order for this community is reported, and the strate-
gies to establish this order in a textual environment are discussed.
Participants went through a cycle of integration into membership, and
some generated distinctive virtual identities or personae. The notion of a
virtual community is critically discussed. Participants interacted as if
they were part of a community, but it is suggested that the interactions
on the list are best understood as extensions of the wider social relations
of general practice. The study of virtual communities may thus have rele-
vance for wider issues of social inclusion and citizenship. The paper also
includes reections on cyberethnography, and suggestions for further
research are offered.
Introduction: computer-mediated communication and
community
This research explores the shape and social order of a discussion
forum established by means of computer-mediated communication
technologies. Networked computers have through the technologies
of e-mail and the Internet created new forums for human inter-
action, with distinctive characteristics reecting the limitations and
possibilities of electronic interaction (Rheingold, 1994; Rushkoff,
1994). Computer-mediated communication (henceforth CMC)
may be expected to differ from face-to-face interaction, yet from a
The Editorial Board of The Sociological Review 1999. Published by Blackwell Publishers,
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sociological perspective, the interactions may be subjected to analy-
sis to discern patternings and routines, social rules and sanctions, as
would an ethnography of a traditional eld setting.
This paper is an ethnographic exploration of one example of such
a social order, an electronic discussion list for UK general medical
practitioners (GPs). But it also addresses the claim made by certain
writers on cyberspace that such networked interactions may lead to
the creation of virtual communities (Sardar, 1996: 2831). Thus
Rheingold (1993) entitled his inuential book The Virtual
Community, while Baym (1994: 161) suggests that these communi-
ties . . . create shared social realities through interactive negotia-
tion. The debate about whether cyberspace interactions amount to
community fractures along lines of whether community is to be
seen as real and essential, or as a social construction dependent on
imagination. As a protagonist of the former position, Sardar (1996)
raises doubts about whether the features of on-line networks such as
norms, criteria for membership and styles or cultures constitutes
community. Real community, he suggests
. . . creates context. It generates issues which arise with relations
to time and space, history and contemporary circumstances, and
require responsible judgement which is why so many issues are
difcult, they require balancing of opposing pressures. A cyber-
space community is self-selecting, exactly what a real community
is not; it is contingent and transient, depending on a shared
interest of those with an attention span of a thirty-second
soundbite. (1996: 29)
However, as Poster (1995) points out, this opposition between real
and virtual is problematic. While earlier forms of community such
as the village were determined by kinship and residence, later
notions such as the nation are highly dependent on imagination
(1995: 88). Part of the complexity of CMC, Jones (1995) argues, is
that it is not just a tool; it is at once technology, medium and engine
of social relations.
It not only structures social relations, it is the space within which
the relations occur and the tool that individuals use to inhabit
that space. It is more than the context within which social
relations occur . . . for it is commented on and imaginatively
constructed by symbolic processes initiated and maintained by
individuals and groups. (1995: 16)
644 The Editorial Board of The Sociological Review 1999
In exploring the sociology of virtually-constructed social spaces,
and the issue whether on-line interactions amount to community,
we can identify various relevant features of CMC. First, there is a
temporal discontinuity to such communication: unlike that other
virtual technology, the telephone, the majority of virtual communi-
ties are currently based on asynchronous communication.
Participants (whether using personal e-mail correspondence or
within a discussion list or bulletin board) need not be on-line at the
same time, and can collect and respond to messages at a time which
is personally convenient. Where participants are geographically dis-
tant, time zone differences can mean communication which spans
hours or days between message and response. This, suggests
Escobar (1996: 123) contributes to a new kind of time, which is nei-
ther circular (as in oral culture), nor linear (as in cultures domi-
nated by books), but punctual.
Second, electronic mail (and other forms of electronic writing
such as World-Wide web (WWW) pages) provides the possibility for
hypertextual links to other blocks of text, ad innitum. Poster (1994)
argues that this further distances a text from its author, fostering a
playful, imaginative subjectivity in the users of CMC, while Landow
(1992) sees in hypertext the empirical support for the post-
structuralist analysis of writing as an endless process of referential-
ity and differentiation (Derrida, 1978).
Third, rules of conduct become established in virtual spaces as in
any other, with rewards for good members and sanctions against
those who break them. E-mail netiquette (standards of conduct)
was rst developed on the Usenet network of about 5,000 news-
groups or bulletin boards and 11 million participants world-wide
who read and exchange news on topics ranging from computer
software to recreational folk dancing. Violations of these codes lead
to reproaches by other users: potential violations include incor-
rect/novice use of technology, sending lengthy (and thus costly to
download) messages, violations of network-wide or newsgroup-
specic conventions, ethical violations such as inappropriate lan-
guage and factual errors (McLoughlin et al, 1994).
These rules of conduct are driven by economic, cultural, and
socio-psychological factors both within and outside the network.
Most CMC develops its own netiquette codes, and these may vary
between communities. A peculiar feature of CMC based on e-mail
technology (discussion lists) is aming: the sending of inamma-
tory messages, often because of an alleged violation of standards
of conduct by fellow participants. Flame wars (Dery, 1993;
GPs in cyberspace
The Editorial Board of The Sociological Review 1999 645
MacKinnon, 1994: 130) may quickly erupt and lead to demands for
expulsions of those responsible.
Fourth, these social spaces generate relationships which become
established despite the lack of face-to-face meetings. Community
spirit might be a good way to describe the
. . . social aggregations that emerge from the net when enough
people carry on those public discussions long enough, with
sufcient human feeling, to form webs of personal relationships
in cyberspace. (Rheingold, 1993)
Rheingold speaks of a gift economy, in which information is given
freely and requests for information are swiftly met: the currency of
this economy is elegantly presented knowledge, while trivia and idle
talk in CMC groups create social cement, as people get a sense of
the others personalities and attitudes.
However, such perceived virtual features of a person may be
wildly inaccurate as a consequence of the mediums anonymity.
MacKinnon (1995) suggests that on-line interactions are conducted
by personae and that the actions and feelings expressed in postings
may not be mirrored either physically or symbolically by their
creators. Gender-bending is one of the more extreme and well-
publicised aspects of this phenomenon. Heavy users of CMC,
according to Baym (1994), thrive on the relational possibilities of
the medium. They form two groups, one technologically astute, the
other relationally astute, the latter social experts focus on the rela-
tional concerns of the group, gaining their power from the ability to
direct the ow of on-line relationships.
Finally, the virtual world is paradoxically both without dimen-
sion, and yet possessing great depths. Rheingold (1993) suggests that
people in virtual communities do everything people do elsewhere,
but we leave our bodies behind, yet our embodiment is socially and
psychologically constructed, and we must acknowledge the complex
psychodynamics of interactions in a virtual community. Stones
research found on-line conference members very frequently referred
to the conference as taking place in an architectural space and to the
mode of interaction in that place as being social (Stone, 1992: 104).
Efforts to make networks seem more spatially real include the cre-
ation of dungeons (MUDs and MOOs) with textually-constructed
inhabitants, architecture, furnishings and other virtual artefacts; in
the future, virtual reality technology may supplement text with inter-
active images (Rushkoff, 1994).
The hidden depths of the dimensionless realms of virtual reality
have been ctionally portrayed in the cyberpunk novels of
William Gibson and such lms as Hackers as dangerous and
intense places in which dramas of love and death are played out.
Thus the motivation to construct virtual spaces, Lupton (1995)
argues, is not only intellectual, but also emotional and irrational.
The body of the computer is enigmatic: what is behind the screen
may be perceived as risky or the site of conscious or unconscious
desires. The search for community may consequently reect both
conscious and unconscious needs of participants in an otherwise
fragmenting world (Springer, 1993: 717).
In summary, CMC is one aspect of a growing dependence on
computers by many people in all aspects of their working and social
lives. The construction of virtual communities may be not only a
substitute for an absence of real-life community, but a place in
which identities are created, developed and perhaps destroyed. It is
also a place invested with power and as such a place in which resis-
tance may be wrought (Critical Art Ensemble, 1994: 25), and real-
world orders challenged (Branscomb, 1993). As such, CMC is
important socially, psychodynamically and philosophically (Land,
1995), and a sociology (or anthropology) of virtual communities
may expect to uncover a richness equivalent to that of a traditional
social grouping or community.
The setting
This study examines the impact of CMC on the social and profes-
sional relationships of British general medical practitioners (GPs).
1
The UK National Health Services Information Management and
Technology (IM&T) strategy is committed to establishing an elec-
tronic network, the NHSnet, which will enable clinicians, managers
and GPs to talk to one another in a secure and controlled environ-
ment, both for financial and managerial purposes and for issues con-
cerning clinical effectiveness and quality assurance (Department of
Health, 1997).
2
The NHS Executive has funded research into how
clinicians may be trained in this newtechnology (Fox et al., 1999), and
the authors of this paper are involved in a continuing programme of
research and development in this arena. At the time of writing, many
GPs are now being connected, enabling electronic communication in
geographically delimited intra-nets and across the wider NHS com-
munity, andre-walled access tothe Internet.
GPs in cyberspace
However, there has been a tendency to assume such new CMC
technologies will serve simply as a more efcient method or tool for
manipulating or improving an existing situation (Hiltz and Turoff,
1978). Even at an organizational level, the access to almost limitless
data and people which the technology offers challenges the conven-
tional pattern of who talks to whom and who knows what (Sproull
and Kiesler, 1991). And, as we have suggested already, there are
other substantive issues which a cyber-ethnography of a virtual
medical community may expect to examine.
The research was conducted on the medical electronic discussion
group (or list) gp-uk, one of many such lists made available by the
Mailbase list-server based at the University of Newcastle, UK.
Using e-mail technology, the list-server is the recipient of mail from
members of the discussion group. Once received, the main is distrib-
uted automatically to the electronic mailboxes of all active sub-
scribers to the list, messages are publicly archived on a world-wide
web site. The list is open to all, although a charter for the list speci-
es that it is intended for the general practitioner community, and
explicitly rules out being used as a medium for members of the pub-
lic to ask for clinical advice.
Joining gp-uk entails sending an e-mail to Mailbase with the
message join gp-uk your name. New subscribers receive an
information pack on how to use the list. Messages sent to the e-mail
address of the list will clearly indicate the senders e-mail address,
and will normally have a title, some text, and the authors signa-
ture. Members can reply to messages, using the same title. A series
of such messages on a topic constitutes a thread.
3
Most participants accessed the list from computers in their work-
place or at home via Internet access providers such as CompuServe.
Members of gp-uk rose over the study period (1 August 1995 to 31
July 1996) from 196 to 443 participants; the majority were British
GPs, with a smattering of other medical and non-medical partici-
pants involved in primary care, plus one or two medical journalists.
The list generated an average of 20 messages per day, making it one
of the most active Mailbase lists. Membership continually changed
as new participants joined and other left, or as groups of partici-
pants left gp-uk to form new, more specic, groups such as a list
called gp-uk-informatics. This was encouraged by the list owners,
recognising that excessive growth of membership could make the list
unwieldy.
Reections on cyber-ethnographic method
The cover of Clifford and Marcuss (1986) book Writing Culture
portrays the anthropologist Steven Tyler in the eld, in India during
1963. The ethnographer is outside a tribal village hut, writing his
eld notes. In the introduction to this book of essays on ethnogra-
phy reexivity, Clifford suggests that this image is itself unsettling in
that the ethnographer hovers at the edge of the frame, faceless,
almost extraterrestrial, a hand that writes (Clifford, 1986: 1). The
nal outcomes of Tylers eld notes were a further text: a mono-
graph which sought to interpret a culture to the (academic) outside
world, and much later a commentary in Clifford and Marcuss
book on the process of textual representation (Tyler, 1986). Texts
are thus key elements in ethnography and textual anthropology
has itself focused on the production of texts such as Tylers mono-
graph (see for example Rabinow, 1986; Atkinson, 1990).
The reader of this text should picture the ethnographer sitting,
not in front of a tent, but before a computer screen, typing on a
keyboard to communicate with a computer generated medical
community called gp-uk. The methodology might be described as
cyber-ethnography, in which research was conducted on a virtual
community which communicates entirely through text. Further, the
ethnographer met with his subjects only within this virtual environ-
ment, yet was a true participant observer, sharing with the group as
it communicated. The textual record formed the raw data for the
project, and through various other textual transformations (log and
diary, preliminary analysis) has been transformed into the text you
now read.
Ethnography is naturalistic, attempting to describe and perhaps
explain aspects of a social phenomenon rather than the testing of a
hypothesis: the thickness (Geertz, 1973) of the description is an
essential element. A fundamental characteristic of ethnography is
observer participation (Hammersley and Atkinson, 1989), requiring
a degree of reexivity both in the observation and the subsequent
analysis and writing. Alongside other realms of technologically
mediated culture (for example, the surgical operating room and the
laboratory), computer-mediated communication is an appropriate
topic for ethnographic effort to research the form and culture of
cuber-communities, and indeed to theorize the kinds of commu-
nity which are possible in cyberspace (Escobar, 1996: 122). The
study of cyberculture, Escobar suggests
GPs in cyberspace
. . . is particularly concerned with the cultural constructions and
reconstructions on which the new technologies are based and
which they . . . contribute to shaping. The point of departure
(cyber-ethnography) is the belief that any technology represents a
cultural invention, in the sense that technologies bring forth a
world; they emerge out of particular cultural conditions and in
turn help to create new social and cultural situations. (1996: 111)
So cyber-ethnographers will document a virtual social world just as
a traditional ethnographer would document a community or other
cultural form. However gp-uk, like other virtual spaces created for
CMC, is a community which exists not in the real world but in a
virtual or computer generated world, created entirely by electronic
circuitry and the electrical impulses which pass through it. It is ren-
dered habitable for humans by the encoding and decoding of these
impulses into shapes on a screen which resemble letters and perhaps
images. If in traditional ethnography there is ambiguity over the
validity of participants representations of a setting, and the subse-
quent construction of an ethnographic text as a second level repre-
sentation of these representations (Tyler, 1996; Armstrong et al,
1997), in the study of a text-based virtual community this ambigu-
ity is total: there is no xed point against which an ethnographic
account might be measured, as there is no underpinning reality
upon which participants representations might be based: the com-
munity exists only in peoples heads. In a nutshell, there is only ever
representation, and that representation is totally divorced from the
only reality there is, namely the passage of electrical charges
through computer circuits (Landow, 1992).
A further difference from traditional ethnography arises because,
whereas a traditional social setting and the ethnographic account of
it inhabit different realms of truth (one being a social space, the
other a text), the ethnographic account of a textual virtual commu-
nity exists in the same realm: both are texts. Thus an ethnographic
account has equivalent epistemological status with any other mes-
sage which forms part of the community. The ethnography and the
community can no longer be separated, and reexivity is also total.
Acknowledging these aspects of researching in a textually-con-
structed virtual setting are important, because they bring into sharp
focus the reexive character of ethnographic interpretation. Just as
participants may construct gp-uk as much more than words on a
screen, the ethnographer may imagine a reality other than the elec-
tronic disturbance caused by participants. Her/his representations,
fed back to participants either during research or in the form of an
ethnographic account, may dramatically affect that community, in a
way less likely (although well-documented in anthropology) in a tra-
ditional setting which is established in non-textual registers.
This issue reminds us of the need for appropriate ethical guide-
lines for cyber-ethnography (BSA, 1992; Rafaeli and LaRose, 1993).
Researchers must decide upon the ethics of remaining as non-
participant (for example, researching an archive rather than a live
discussion list), to lurk as part of the list but without active partici-
pation (covert research), or to accept the potential for distortion of
the study setting by becoming an active member (overt participant
observer). As with other eld settings, ethical disclosure of a
researchers identity and the possibility of observer bias, with conse-
quent loss of validity, are in conict with each other (Allen, 1996).
If one takes as a basic ethical principle that those researcher
should not come to harm as a consequence of research (the princi-
ple of non-malecence), then cyber-ethnographers should seek
informed consent from their subjects (Reid, 1996) and respect pri-
vacy and subjects dignity (Marx, 1998). This principle has been
questioned where electronic spaces are public (for example, gp-uk is
archived and anyone with an Internet connection may read the mes-
sages posted without joining the list and disclosing their own iden-
tity). It has been argued by regulatory bodies such as university
review boards that in such situations, researchers are exempt from
normal requirements to gain informed consent (King, 1996).
However, a distinction may be made between that which is publicly
accessible and that which is publicly disseminated. Because interac-
tions may be accessed does not conrm the right to disseminate
them for example through research papers or journalistic articles
(Waskul and Douglass, 1996). Furthermore, researchers must be
aware of the dis-inhibiting effect of on-line communication media,
in which people may disclose more than they might in face-to-face
situations. Researchers should take responsibility to minimize the
harm which might result from such dis-inhibited exposure (Reid,
1996).
In the present study, the decision was made that the researcher
[CR] should become an active member, both for ethical reasons and
to enable the kind of enquiry which an ethnographer might adopt in
a traditional setting, not only observing, but also asking questions
and occasionally testing out ideas with participants and key infor-
mants to gain a clearer understanding of a culture, and nally to
experience the list as a participant might. It was acknowledged that
GPs in cyberspace
this could lead to bias, as participants might alter their on-line
behaviour because there was a researcher present.
4
CR introduced
himself to the list as a GP currently studying as a postgraduate stu-
dent who wished to research gp-uk, and permission was granted for
this research by the list owner. There was open discussion of his
project by participants in the discussion group from time to time,
some of which are documented in this paper. The other author [NF]
joined the list as a lurker or non-participant observer, to get a
sense of the environment as part of his responsibility to supervise
CRs eldwork. The list was accessed from networked computers in
the Institute of General Practice and Primary Care, University of
Shefeld, using Pegasus Mail for Windows software.
All messages posted to gp-uk over a 12 month period were read,
and these formed the principal database for the study. Other data
included
private mail generated by CRs participation in the list
discussions between the authors of this paper and with other
researchers of virtual communities
searches of the gp-uk archived messages.
The data was analysed using the computer software package
NUD*IST (Scolari, 1995)
5
which permits large quantities of quali-
tative data to be coded and interrogated. In the following section we
offer examples of messages to support the ndings. Exact spelling
and format are retained; all mail messages were in plain upper- and
lower-case type only, italics indicate interpolations by the authors of
the paper to clarify meaning.
In this paper we are less interested in the content of gp-uk mes-
sages (which largely comprised discussions of professional issues)
than in the social order of the list. Thus after a brief look at mes-
sage content we focus on the reasons given for participation in the
discussion list, informal rules and norms, and the social construc-
tion of members cyber-identities.
The content of gp-uk messages
The messages sent (posted) to the discussion list may be categorised
into information offering, information request, opinion offering,
opinion request, and what might be described as formative messages
which help to establish and sustain interaction. As such, the list is
equivalent to most kinds of face-to-face communication media.
For many participants, the information-sharing aspect of the list
was the most signicant, and they sought a model of the list which
has been called a discretionary database (Rafaeli and LaRose,
1993), in which information is provided to meet the needs of the
participants. Such information might be a summary of locally pro-
duced clinical guidelines, the results of a survey, expert knowledge,
or the recommendation by the author of someone deemed a source
of information, or references to published material. On occasions,
participants would send world-wide web (WWW) site addresses
where relevant information was held. Sometimes, information was
given whether asked for or not, because the contributor felt it would
be of mutual interest.
This information may be of use:
DIRECTIVE 95/EC OF THE EUROPEAN PARLIAMENT
AND OF THE COUNCIL ON THE PROTECTION OF INDI-
VIDUALS WITH REGARD TO THE PROCESSING OF
PERSONAL DATA AND THE FREE MOVEMENT OF
SUCH DATA (FINAL) ADOPTED BY THE COUNCIL IN
JULY 1995 [DM]
Information would be requested on occasions, using the list as an
informed resource which could provide information more quickly
than through other search strategies. These might be requests for
examples of good clinical practice, research ndings or other
resources.
I am interested in any learning resources that have been or are
being developed for medical student training in general practice.
In particular, I would be grateful for any information about
computer aided learning [SD]
Two days later, this request received the reply Try Bob Price in
Arkansas he has done a great deal of work in this area [JW].
For these participants, the list was principally a place for
information exchange rather than for social or professional func-
tions. Many had joined the list because of an interest in information
technology and informatics, and this was reected in the use of
computer jargon, synonyms, and acronyms which peppered the
messages. Recurring themes of security of computer systems, con-
dentiality and access to electronic information, and discussions
about the quality of electronic information would lead to highly
GPs in cyberspace
technical information-sharing about the capacities of different hard-
ware.
However, the list was also a medium for sharing opinions. Once
again, computing and informatics was a frequent theme.
Just as it is unthinkable that an illiterate person could practice as
a GP, so I believe that it is becoming increasingly unacceptable
for GPs to become computer illiterate. In my view the ability to
use computers within the consultation is an essential skill and
should be taught in the vocational training schemes and tested in
the MRCGP (GP Professional Examination). [TL]
However, virtually any topic might become the subject of a posting.
Personally I wonder about looking for a progressive general
practice. I have to ask in what way progressive? If you nd a
family doctor who you like on a personal level and respect on a
professional level that is a good start. [IS]
Such messages would often stimulate responses and lead to
threads (series of messages with the same subject line, and on the
same theme) lasting days or weeks. Frequent popular threads con-
cerned the pressures on general practitioners, and the psychological
and social stress the NHS reforms had wrought.
On the same theme, does anybody else think that EBM (evidence-
based medicine) is a backlash against the saintly evaluation of
illness in physical, social and psychological terms that eventually
turns anyone who tries it into a burnt out wreck? [DJ]
I often think that the main reason for the distress of many GPs
these days lies not so much in our working conditions and pay as
in the pressure upon us to change our culture. We are in a position
analogous to a subject people which has been taken over by a
colonial power which not only wishes us to change our behaviour,
but believes that its attitudes and culture are superior. [TL]
The list provided a forum to debate the working conditions in general
practice and given the audience was a place where opinions could
be voiced relatively freely, often leading to extensive discussion.
Wither the exhausted practice? Too few hours currently in the day
for partners to do the management work and see all the patients,
too little money to employ assistants and locums to give us the
free time to enjoy a lifestyle half-decent compared to that of the
GP in say 1975. [PS]
Finally, a number of messages were reexive about the list, and
served, intentionally or unintentionally, to support the virtual com-
munity.
I for one have learnt a great deal from this community. I mean
learnt stuff that was relevant to me in the context of medical
practice . . . There is a denite process of dissemination here.
[AR]
[AR] and I are having some quite in-depth communications
directly. Hes really mad like me :-) We are getting on really well.
[DJP]
Participants might encourage the list to continue its interactions,
posting such messages as This is a non-inane posting intended to
stimulate debate [TL], although other postings acted in the oppo-
site direction.
. . . the volume of garbage received over the weekend does not
bode well for this (list) being a useful asset for my general
practice development. [JM]
In summary, the list served as a collaborative medium, in which the
audience was both creator and receiver of the mediums content
(Rafaeli and LaRose, 1993). While information sharing was a fea-
ture of the list, contributing to a discretionary database of useful
information, opinion and group support were also strongly featured
in message content.
The social order of gp-uk
Reasons for membership
The ofcial rationale for the existence of gp-uk offered by the list
owners to all new subscribers was that
. . . gp-uk facilitates discussion on new ideas, research workshops,
seminars, conferences, grants, education, software development
GPs in cyberspace
etc. for the UK General Practice (Family Medicine) community.
Non-UK views are also welcome. Gp-uk intends to promote
collaborative work, problem solving and support.
Some participants appeared to endorse this catholic mix of profes-
sional aims and opportunities to share information.
I like the way the list demonstrates the use of technology to allow
GPs to communicate with one another on a wide range of topics.
[DM]
Im not a clinician, but my job requires an awareness of health
telematics specically in the NHS. Gp-uk is one source of
information, of interest because members have by denition a
greater awareness of, and an interest in the subject. [RW]
Participants were attracted to the list as a community of general
practitioners. The coffee break was a metaphor used more than
once, sometimes nostalgically.
The balance of humour, seriousness, clinical and scientic reect
the sort of conversations I have with my own local colleagues
over coffee in the practice, but which unfortunately there are less
and less time for. [AC]
. . . gp-uk [is] like morning coffee break. Most people nd it
useful. Supportive and cathartic, but there are some who prefer
to shut themselves in their rooms and do paperwork. [JA]
Making contact with colleagues of a like-mind was a reason for reg-
ular participation, and the medium had characteristics of freedom
of expression not easily found elsewhere.
Obviously you have to pick the relevant subjects to read, but the
breadth of opinion and information is relieving (not revealing!).
Im so glad that there are other mad, angry GPs out there! [DP]
From time to time, members would decide to leave, and might offer
reasons. Often these reasons concerned one impact of the growth of
gp-uk: the increasing volume of apparently trivial messages.
I do not like the time I spend reading contributions that while
interesting are of little relevance to me. [DM]
I agree with your sentiments about this list. Having just wasted a
lot of time downloading 47 short unhelpful letters I am leaving
this list. [MD]
Social norms in the community
In a monthly list review, the list owners of gp-uk articulated general
guidelines (netiquette) for the discussion: for example, a reminder
that gp-uk was an academic list, or that if a member wished to
reply personally to the author of a message, then personal e-mail
should be used rather than a list-wide message which would be irrel-
evant to all but the intended recipient. Against this formal set of
rules, more informal norms emerged. For example, a convention
of the list was that new participants lurked for a while before con-
tributing, to attune to the mores of the list. Indeed some partici-
pants seemed to be permanent lurkers.
I have been lurking on the group for 12 months now, and while I
accept that lurkers contribute little to the community, there is a
lot of general support and ideas to be found from reading
discussions of people with the same job and its problems in the
1990s. [AC: private communication]
While lurkers are encouraged to make themselves known by other
members of the list, sometimes the environment seemed threatening
to those who had not become accustomed to the rough-and-tumble
of discussion. Lurking was perceived as secret and perhaps shame-
ful.
I spend a lot of time icking furtively through the magazine of
gp-uk sometimes I think of buying even though it is likely to
provoke the sort of response that sends a lurker scuttling into the
street to melt into the crowd again. [SB]
While sitting in a seminar of paediatric [doctors] in Newcastle
yesterday I had a rather unnerving experience. I signed and
printed my name on the attendance register and passed it to my
neighbour who said your on gp-uk, arent you. [MP]
Newcomers would learn the rules of interaction, including the
abbreviations used by regulars in messages such as IMHO (in my
humble opinion) and BTW (by-the-way). There was no shortage of
advice for newcomers. An experienced participant suggested that
GPs in cyberspace
. . . there are plenty of perfectly sensible, useful and practical
discussions and you shouldnt miss out on them just because you
have come across a few GPs letting of steam. [TL]
The social order of the list was continually being negotiated by par-
ticipants who had varying views of its function and how its mem-
bership should behave. Increased volume of trivial messages often
led to exasperated comments.
Am I to expect this is the purpose of the group, and that the
stated aim to be an academic forum is inaccurate? [JM]
The domination of list discussions by a few high prole personali-
ties was raised as a continuing problem for new participants, argu-
ing that their behaviour was inappropriate.
Sadly this list seems dominated by two doctors, whose posts to
this list can be thoughtful, helpful provocative, funny (and other
positive adjectives) and for that I thank them but whom some of
the time clutter up this list with posts which are a waste of space,
composing multiple copies . . . [LM]
These two characters can be quite unpleasant and abusive to
newcomers and make this list an unfriendly place. And they
justify it by claiming freedom of speech. When will they realise
that they are putting off newcomers to this list? [LM]
The targets of such messages were of course party to such criticism.
When accused of being responsible for a mass of inane consequen-
tial and pointless communication, IH replied
Unless I am being overly sensitive, which I doubt, you Sir, are
referring (at least in part) to me. Frankly, I am insulted . . . [IH]
The dominant voices on the list were also overwhelmingly male, a
feature which has been recognised as common to many such virtual
fora (Spender, 1995). On one occasion, a participant wondered
where were all the female contributors to gp-uk. In response, one
of the few women on the list replied
I think Im it chaps ;-) but FS occasionally feels moved to
comment. [ST]
Construction of cyber-identities
The nature of an e-mail list necessarily reduces clues to identities
available to people in face-to-face communication. On gp-uk there was
not complete anonymity, as e-mail addresses normally contained
some element of an authors name. Furthermore, because names and
other details were required to register on the list, these were available
through the Mailbase web-site, for those who wished to nd out more
about a participant. However, most members of the list chose to esh
out these bare bones of identity in a variety of ways, and the develop-
ment of distinctive personalities or personae by members of gp-uk
was a collaborative activity. One way in which such persona formation
began was through the kinds of messages posted. Thus, one Saturday
afternoon in March 1996, ve messages arrived from IH with the dra-
matic titles Defeating Depression, Wet Babies, Burnout, Lateral
Thinking and (Dr) Osteopath. Another frequent poster, AR, was
asked how he could sustain his output on the list.
As for the time bit, well I dont drink, I am now monogamous, I
dont do on-call . . . and I nd human company after a long day
spent with a deluge of whinge a little disturbing . . . [AR]
Once a participant had established a persona, s/he might be suf-
ciently condent that the list had a clear concept of his/her identity
to appreciate an irony.
This will cheer you, though. Ive been asked to be a group leader
at ( . . . ) [a week long accredited GP educational course] next
month! Me! Ha-hah-hah! Can you imagine it? [IH]
Some members sought to locate and dene themselves as technical
computing experts, through association with others with technical
expertise, or through their attitude to the lists purpose.
You are posting to several people who wrote or specied parts of
the donkey (GP computing system). I myself pinned tails on
several places. If you can give a clear example of a way in which
one screen of one system can be improved in use or clarify then
you have a very reasonable chance of the improvement appearing
in (commercial GP computing system). [AM]
(We) want to use the Internet to encourage best practice and the
highest standards in primary care. [KH]
GPs in cyberspace
Even those leaving the list might try to create an identity for them-
selves.
This is a brief good-bye . . . the time taken to wade through bits
that interest me is no longer justied. . . . In the meantime if you
want to include me in circulation on any topic that relates to
information systems please send a personal e-mail to . . . [DM]
The attribution of personality characteristics to others on the list
assisted this persona formation.
I think ARs consulting room is jet black and scarlet, divided by a
dramatic zigzag line extending over two walls. I suspect AH of
magnolia and IT of some sort of government buff. [AM]
An interesting example of this attribution of identity occurred dur-
ing an on-line discussion of the researchers (CR) methodology as
participant observer. One member argued that
you shouldnt be posting on (gp-uk) because by doing so you
disturb the community from its native state. [PJ]
Other participants continued this thread.
In this case Chris isnt really doing research but wishes to create
an e-mail persona that suggests he is. [DM]
Yes I agree this makes me nervous too a bit like time travellers
messing up the future by changing the past. Has any of your
nearest and dearest started to disappear from their photographs?
How many posts would not have happened if Chris had not
intervened. How many lurkers have been outed? A mere ap of
the butterys wing . . . ;-) [JW]
A more stylised mechanism for creating self-identity was through
the use of signatures, added automatically to outgoing messages
by the software, in addition to the e-mail address of the sender and
a name. Generally features which were included in signatures were
full name, main occupation, any additional posts held, and contact
addresses (voice, e-mail and in some cases web sites created by the
holder of the signature). Signatures might be embellished with sim-
ple artwork, using keyboard symbols, as in Figure 1, or with a quo-
tation or slogan.
-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-)
[ST] Fax 01529 460589 / 01522 569874
Editor Informatics
http://www.ncl.ac.uk/~nphcare/PHCSG/Journal/index.htm
The Journal of Informatics in Primary Care
PHCSG The British Computer Society
-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-):-)
Figure 1 Signature created in keystrokes
Other messages might have only informal signings-off: regards
or cheers, offering no clues to identity, either seeking anonymity or
claiming the familiarity of the well known.
Finally, members might try to introduce some identity or aspect
of their personality into messages through the use of symbols built
out of keyboard characters and punctuation marks. These emoti-
cons were used to smile :-) to wink mischievously ;-) or to frown :-(
and offered cues to a reader as to the vein in which the statement
should be taken. For example, in reply to the question posed on the
origin of the expression loo
Why the hell am I bothering to reply to this question?? After all I
knew it was a trap to prove gp-uk junkies will respond to any-
thing ;-) [JW]
The emoticon here tempers what at rst sight may have appeared an
irritable outburst. Some users had a more extensive or sophisticated
dictionary of emoticons, such as one representing a bearded face,
used to send a message to a professor of physics, perhaps indicating
the recipients ascribed wisdom.
Perhaps you can answer that MW? My knowledge of physics is
on par with my knowledge of why the n is silent in autumn ;-|>
[AR]
In summary, many participants sought to establish aspects of their
real identity in the virtual environment. There was no evidence of
the intentional identity-bending or gender-bending reported by
Rheingold and others, perhaps reecting the initial registration of
members details and the explicit professional and educational
objectives of the list outlined by the owners and documented earlier
in this paper.
GPs in cyberspace
Professionalization, inclusions and exclusions
The social order of the list was enhanced by interactions which
addressed issues of professional closure. Discussions around matters
concerning the position of doctors (and general practitioners in par-
ticular) often had the tone of a siege mentality, with anxieties over
perceived challenges or threats in the wider political and social envi-
ronment as frequent themes for threads. Doubts over an alteration in
medico-legal practice concerning disciplinary hearings (service com-
mittee) was raised as a semi-joking addendum to a social posting.
Good luck with your lecture. How many of your audience realise
that since 21.12.95 GPs can now be suspended prior to a discipli-
nary hearing by the chairman of the service committee, and the
right of appeal to the Secretary of State has been abolished? [GP]
The belief that new technology was going to deregulate medicine
and further problematize power relationships received frequent air-
ing.
Dr ARs selective quotation from an e-mail of mine may have
given the impression that I was only or even mainly consider-
ing the likes of the GMS to be the powerful interests which could
get very scared if the Internet forcibly deregulated the business of
medicine. [RA]
The mood of disillusionment sometimes merged into despair, as
members of gp-uk reected on the conicting demands of patients
and their own well being.
I have burnt out once and cut down my work and reorganised my
practice and got my partners to do more and taken a cut income
and still feel that there is no way that I am doing what I entered
medicine for. I cannot do all that I trained for. [TR]
Many of these serious reexive commentaries would be given a twist
through the use of irony, providing social cement for discussions
which were often challenging or poignant. Irony might be dened as
the juxtaposition of apparently disparate elements in a manner that
highlights and problematizes each of them (Brown, 1977). For
example, a message entitled barriers suggested that these were
needed to prevent interruptions to work in the surgery.
. . . with an open surgery every morning and no shortage of
patients willing to open their hearts to me in the time-honoured,
While Im here Doctor fashion, I think I would be better off
trying to raise a few barriers instead of breaking them down. [IH]
The replies to this message suggested that the respondents detected
the irony and countered with what would appear to be further
ironies of their own:
One barrier I have found useful is to dress absolutely formally:
Pinstriped suit, waistcoat . . . it did seem to reduce the length of
chummy, tired all the time consultations . . . perhaps it is time to
revisit other techniques yawning, avoiding eye contact, staring
out of the window, icking through the les of the patient yet to
be seen, frequent watch checks, or perhaps just falling asleep. [JL]
The use of irony in such messages was not appreciated by all partici-
pants, and it was recognised that sending ironic messages could be
risky, as the absence of cues in electronic mail could cause problems
of interpretation.
With e-mail you click the button and thats it, its [the message]
gone. Something about e-mail deadens the wit, sharpens the
sarcasm and winds up every ones paranoia, so something meant
as a joke can be read as a deadly insult. Weve seen a few exam-
ples of natural paranoia being wound up in recent threads. [AH]
The failure to identify efforts at irony or humour often led to mis-
understandings, and the stability of closure was challenged as
respondents echoed or refuted the sentiments expressed. As such,
the community was continually under negotiation, and from time
to time calming words were needed to sustain its integrity as a
ame war threatened to erupt.
Discussion
In what sense is it reasonable for sociologists to ascribe the term
community to a set of individuals, isolated geographically and
communicating with each other asynchronously? At a trivial level,
the answer to this question might hinge upon characterizing an
essential community, thereby excluding everything which did not
GPs in cyberspace
possess the appropriate features, such as geographic proximity or
shared interests. It is this approach which leads Sardar (1996: 29) to
reject CMC as constitutive of community, in that it lacks any sense
of commitment, continuity or context.
Other writers within sociology have sought to problematize the
notion of community itself, acknowledging that in post-traditional
societies the creation of a sense of community around such ideas as
the nation and class are largely conceptual and a consequence of
imaginative construction (Anderson, 1991; Poster, 1995; Wagner,
1994). Wagner sees imaginary community as a feature of moder-
nity, while Bauman (1992) connects the construction of imaginary
community to the logic of post-modernity, arguing that what such
communities lack in stability and institutionalized continuity, they
more than compensate with the overwhelming affective commit-
ment of their self-appointed membership (1992: xviiixix). The
work of constructing community or post-modern sociality serves
to elaborate a logic of identication involving personae with vari-
ous masks (Maffesoli, 1990: 92). Poster argues that the virtual com-
munity of cyberspace is suited to a postmodern uid subjectivity
(1995: 8990).
Virtual communities derive some of the verisimilitude from being
treated as if they were plain communities, allowing members to
experience communications in cyberspace as if they were embod-
ied social interactions. Just as virtual communities are under-
stood as having the attributes of real communities, so real
communities can be seen to depend on the imaginary: what
makes a community vital to its members is their treatment of the
communication as meaningful and important. (Poster, 1995: 90)
As Wagner points out, despite notions such as nation and class
being imagined communities, for participants they seemed very real
and were perceived as the natural locations of human beings in post-
traditional societies (Wagner, 1994: 1834). From such a perspective,
the task of cyber-ethnography is more to do with exploring the on-
going reexive construction of social spaces and identities than with
arguing whether virtual spaces possess particular attributes of real
communities. What this research on gp-uk illustrates is that the par-
ticipants behave as if they are part of a community. Firstly, there is a
social order to the list, but perhaps more importantly, and contra
Sardar (1996), there is also a context to the interactions, which is the
real-world concerns of general medical practice.
Considering the social order of the list, this research suggests that
interactions are constrained by rules of conduct, and there are sanc-
tions if these are broken (primarily public denouncement, although
in theory members can be expelled if they behave in a way deemed
unacceptable to the list owners); the messages adopt shorthand and
jargon; there is a perception of the list as having grown organically,
there is a use of humour, and the list is archived. Stone (1992) sug-
gests that a further characteristic of electronic communication is
that participants act as if they were inhabiting physical space, and
this research offers some support for this proposition, for example
in the forms of greetings, which ape face-to-face rather than paper-
written communications, and in references to the list as like a staff
coffee-room.
While there were no obvious characteristics which predicted
whether members would be regular participants or lurkers, the
research suggests distinct stages of participation as identied by
Baym (1994) and McLoughlin et al (1994). Such stages of participa-
tion are not dissimilar from those found in face-to-face groupings,
and no doubt contribute to the reexive sense of community which
the list engenders. Thus a new participant may move from being a
lurker, to the novice stage, to being a regular contributor and per-
haps to become a frequent contributor or heavy user. Participants
may remain at any stage, regress or in time leave the list temporar-
ily or permanently. Those newly joined to gp-uk describe the lurking
stage as one of increasing understanding of how the community
works, but also as one of trepidation in contributing. Heavy users
are perhaps the only ones to exploit the full potential of the medium
for play, and have the most clearly dened personae. Castells points
out that the members of virtual discussion groups divide into
. . . a tiny minority of electronic villagers homesteading in the
electronic frontier, and a transient crowd for whom their casual
incursions into various networks is tantamount to exploring
several existences. (Castells, 1996: 362)
In addition, we may see features of a learning community in gp-uk.
Saunders (1995) offers a typology of learning which runs from
immediate (learning which addresses urgent problems) to organic,
which describes communication between members of a dispersed
group which nevertheless have a strong and well dened set of
shared occupational goals, ethics, objectives and values, is driven by
a high level of professional commitment, and is characterised by
GPs in cyberspace
informality, scattered topics, and highly volatile structures. This lat-
ter model of learning fairly accurately describes the interactions on
gp-uk, although participants are not explicitly engaged in profes-
sional development.
However, in the light of the earlier discussion of Posters (1995)
critique of an essentialized community, it is inadequate to simply
list the attributes which gp-uk has in common with real communi-
ties. Certainly we can see several strategies adopted by participants
to establish and further the illusion. Messages use textual symbols
to mimic facial expressions, signatures establish cues and contexts
for the interpretation of messages, and the informality of the com-
munications fosters warmth and camaraderie. However, what is also
needed is a contextualization: to grasp how the virtual community
is situated within historical circumstances. What are the motivations
of participants, such that they engage in on-going cognitive work to
construct a shared sense of something other than a series of textual
communications on their computer screens? May we understand a
virtual community such as gp-uk in terms of its embedding in the
social and economic relations of the wider society to which partici-
pants belong: a society in which, perhaps signicantly, any sense of
community is only weakly present (Robins, 1995).
It is the referentiality of so many messages to a reality beyond
the list which seems to differentiate what happens on a list such as
gp-uk from the transient and inconsequential model of cyberspace
which Sardar (1996) invokes. There is evidence from the data in this
research that participants construct friendships and alliances in gp-
uk, as they might among a face-to-face general practice community.
perhaps it is the collegiality of this group which leads it to invest
their virtual interactions with features of community: a spirit of
mutual trust, responsibility and an on-going commitment on one
hand; on the other, the petty spats and aming which also mirror
the tensions which arise in face-to-face engagements.
We need to understand the sociology of this virtual community
in relation to the wider social and psychological environment which
spawned it. General practice in the UK is a traditionally frag-
mented specialty within medicine, in which small groups of practi-
tioners work in isolation from their peer group, with rare
opportunities for collegiality. In addition, it has been the subject of
radical structural and cultural reforms during the 1990s, and it has
been argued that for many GPs, their professional lives are now
characterized by stress, poor rewards and disillusionment (Mathers
and Gask, 1995). Perhaps for this generation of GPs, gp-uk offers
an environment which may seem far more secure and communal
than the surgery or staff common room. It may also be a place in
which such beleaguered souls can explore their identities, try out
ideas and opinions not appropriate in face-to-face situations, and
assert their resistance to the oppressive circumstances in which their
real-life personae operate. The liberation which CMC offers may
be libidinal as well as instrumental (Lupton, 1995), while the utopia
of virtual community operates in the context of a dystopic reality.
The social and power relations of general practice are reected in
the exclusion of patients from discussions (only on one occasion
during the study period did a patient manage to inltrate the list,
and only then under the sponsorship of a GP member: the subse-
quent discussion was conducted under the subject line Yer Actual
Patient). Issues of power may also be reected in the gender mix of
active participants in gp-uk. Cyberspace has been recognized as a
peculiarly male-dominated and sexist place to visit (Sardar, 1996:
246), and the lack of regular female voices on the list supports
Spenders (1995) argument that women get even less conversational
space in a virtual world than they do in real life (p. 196). Her discus-
sion of the dynamics of computer-mediated communication notes
that users can behave in a much more abusive and crudely coercive
way when they are anonymous, than they would in face-to-face situ-
ations (1995: 195), and such behaviour is certainly evident in the
occasional ame wars on the list. While the list is a space for
frankness and for the airing of opinions, it is also a public place in
which participants are highly vulnerable to challenge in ways which
are rare in professional circles. Even the hardiest ego may be threat-
ened in such an aggressive environment. There may also be struc-
tural reasons for the gender bias on gp-uk. Given that many
participants access the list from home, perhaps at odd times of the
day or night, this may militate against female participation because
of traditional divisions of labour within the home. Once again the
social relations of the virtual space mimic those of reality: medi-
cine remaining a difcult profession in which to combine work and
family commitments.
In conclusion, this research supports Schroeders (1995) argument
that part of the sociological signicance of new technologies lies in
their ability to intensify and extend human beings attempts to manip-
ulate the natural and social world. The as-if-it-were-a-community
character of discussion lists of gp-uk (and participation by the authors
in other lists indicates that gp-uk is not unique in this respect) demon-
strates an extreme example of the on-going construction of imagined
GPs in cyberspace
community. The social order of computer-mediated community is
reected in the social norms of the list, the strategies used to establish
identities by participants, and the closure around professional values.
Yet this social order is also a feature of the wider context of social
relations within which computer-mediated communication takes
place. If the future shape of society includes the proliferation of vir-
tual communities, explorations of these cyber-spaces may give clues to
the social relations beyond the computer screen and world-wide web,
and have implications for social inclusion and citizenship. Thus there
are several avenues for further enquiry. For the cyber-ethnographer
and social theorist there is a rich source of material here, concerning
the construction of virtual communities and virtual identities by those
who use computer-mediated communication and interaction media,
the social relations which develop in such environments, and the rela-
tionship between life in such hypertextual environments and the loss
of certainty in late- or post-modern cultures (Landow, 1992; Poster,
1995). For the educationalist, the use of such virtual environments
suggests possibilities for classrooms in which tutor and students inter-
act as if they were face-to-face. The authors of this paper are
involved in on-going research for the NHS and Department of Health
to explore the possibilities of virtual classroom in professional educa-
tion and the dynamics of discussion groups (Fox et al, 1999). For the
research methodologist, studies of virtual settings (in which reality is
entirely constructed in representation) raise issues concerning the
validity and reliability of research reports which are also pertinent to
the social study of traditional settings (Tyler, 1986; Armstrong et al,
1997).
University of Shefeld Received 29 January 1998
Finally accepted 19 November 1998
Notes
1 In the UK, general practitioners are self-employed, and may set up as single-
handed practitioners or more usually within multi-partner practices employing a
range of health care, managerial and administrative staff. They receive government
funding based on capitation payments for their patient list, and for items of service
(consultations, home visits etc.). General practice is the point of rst contact with
health services for the overwhelming majority of patients, and this system of pri-
mary care acts as a gatekeeper into free NHS secondary care. NHS reforms in the
early 1990s enabled some GPs to hold funds to purchase secondary care for their
patients, although this system has now been replaced by groupings of practices
(primary care groups) which coordinate primary care in a geographical area and
commission care from secondary care trusts. The commitment in government pol-
icy to a primary care-led NHS (Department of Health, 1997) has increased the
power of GPs in relation to hospital medicine.
2 The driving force behind the NHSnet has been the possibilities for transferring
patient data electronically for clinical as opposed to managerial purposes. The
technology was delayed for some years because of problems of condentiality, to
create a re-wall impervious to outsiders while enabling NHS staff to use the
NHSnet as a route into the Internet.
3 The sending of messages and their reception are not necessarily temporally associ-
ated, so on occasions participants may receive or read replies to messages before
the original message which stimulated the response. This contributes to temporal
disruption of communication on the list and to the indeterminacy of message con-
tent.
4 People joining the list after CR declared his role as researcher may have been
unaware that he was gathering data from the list. This raises the unresolved ques-
tion of how to establish on-going informed consent in a changing environment
(Waskul and Douglass, 1996), where a researchers presence can only be gleaned
from an archive of messages.
5 NUD*IST is a software package for analysis of qualitative data. It enables coding
and manipulation of large quantities of text generated by qualitative research, and
mimics the activities of cut and paste analysis with the added value of enhanced
conrmability. Its title stands for Non-numerical Unstructured Data Indexing,
Searching and Theory-building.
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