AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. July 2011, Volume 13, Number 7: 440-447.

Clinical Cases

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Anonymous Physician Blogging

A physician blogging anonymously risks breaching patient confidentiality and misrepresenting the medical profession.

Commentary by Bryan S. Vartabedian, MD, Emily Amos, and Jay Baruch, MD

After a long day at work, Dr. Baker sits down to check her email and finds a forward from an old medical school friend. “I thought you’d enjoy this,” her friend has written. The link takes her to a blog called “theGrouchyMD: musings of an overworked Texas OB/GYN resident.” The first posts tells the story of “Jane,” a 53-year-old woman trying to get pregnant. The blogger expresses the opinion that “Jane may be well intentioned, but I can’t help thinking that what she’s doing is selfish and irresponsible” and posts some links to news articles on uses and misuses of reproductive technology. A lively debate follows among blog readers, who identify themselves as members of the public, medical students, and other physicians. Earlier posts are on topics ranging from health care reform to “war stories” (“Caught a twin vaginal delivery today,” reads one post, “textbook! Now that’s real obstetrics!”). Some posts are centered on readers’ questions, like one explaining the differences between some types of oral contraceptive pills.

As she scrolls down, Dr. Baker becomes increasingly concerned; the patients begin to sound familiar, as do “Dr. B” and “Dr. H,” theGrouchyMD’s colleagues. The blogger apparently not only practices in the same hospital as Dr. Baker does, but appears to be in the same program. The next day, Dr. Baker confronts Dr. O’Connell, her fellow third-year resident. “You’re theGrouchyMD, right?” she starts. “I’m concerned about what you’re doing. I know you changed the names, but what if someone recognizes herself? Sometimes you say some pretty edgy things about the hospital and the residency. What if someone in admin gets hold of it? I’ve also heard of blogs getting used in malpractice suits. Did you think about that when you talked about the placental abruption Dr. H missed last month? And what about you giving people advice on there—I don’t think that’s very smart either.”

Dr. O’Connell sighs. “Look, sometimes I just need to vent,” she says. “I don’t think I’m hurting anybody. I change all the names and identifying information, I always ask if I’m going to put up a picture, and I never give people advice about their specific medical conditions. I think it’s really useful for people to get sensible general advice on their health from a real doctor, not just whatever junk is out there on the web.”

Dr. Baker replies, “I don’t really have a problem with your blog, I just don’t think you should talk about patients or the hospital on there.”

Commentary 1

by Bryan S. Vartabedian, MD

As a physician active in the health blogosphere since 2006 and Twitter since 2008, I’ve had the opportunity to watch the adoption of social media by the medical community. Over the course of just a decade, many of us have evolved from audience to publisher. With the ability to publish has come the responsibility to conduct ourselves professionally both as physicians and citizen journalists. I’ve personally had to confront many of the professional issues facing doctors in this new medium. The vignette presented showcases nicely some of the challenges facing physicians in the social-media space.

Social Media Challenges

The discussion of patient-specific information in the public arena. With the power to share stories comes the power to share stories about patients. This creates a problem for the physician engaged in social-media publishing. Patients may not want their care discussed and the law prohibits the disclosure of protected health information. Some physicians who share patient stories de-identify information through the alteration of critical details. But it’s important to realize that a physicians obligation to her patient is not defined only by federal law. Consider the physician who properly de-identifies patient information and discusses the case in a public forum. If that physician’s patient were to see the blog post or Tweet, it could interfere with the relationship. Our commitment to patients goes beyond HIPAA. The safest strategy for physicians tweeting, posting, or writing online is to avoid any discussion of patient-specific information.

The danger of anonymity. One strategy employed by some physicians on social networks is the use of an anonymous profile. “If no one knows who I am, I can’t get in trouble,” the reasoning goes. The problem is this: there is no such thing as anonymity. People writing under pseudonyms can be easily identified. Anonymity also confers a false sense of security, tempting us to say things that we otherwise might not. The fact that my name and picture sit to the right of every blog post makes me think long and hard about how my ideas will be perceived. I understand that everything I write will be seen by my department chair, wife, mother-in-law and patients. That’s a powerful check on bad behavior.

Immediacy. When I speak to physicians I always like to make the point that the challenges we face today with social media aren’t much different than those faced over the past few generations. Blogs and Twitter for doctors are not fundamentally dissimilar to letters to the editor, articles, or other traditional forms of communication. I think this comparison drives home the point that it isn’t the written word that’s changed, just the way that it’s delivered. Self-publishing doesn’t have a check on it in the form of an editor.

The most obvious difference is the immediacy of communication. Dialogue can take place in real time. Both Twitter and Facebook allow us to share text, video, and pictures of events almost as they happen and to respond to others’ posts as fast as we can type. With this immediacy comes the risk of publishing before thorough consideration of the consequences. Impulsive, emotional communication can create problems. And a hasty thought or word can spread very quickly once published.

Minding your digital footprint. Another difference between old and new media is that today our thoughts and ideas are easily and permanently retrievable. That edgy letter to the editor that was published 20 years ago now lives only on microfilm. Tweets, blog posts, and Facebook entries become an immediately retrievable part of what we refer to as our “digital footprint”—the searchable body of online behavior that increasingly defines us. While some physicians think about their digital footprint with a certain level of fear, it’s important to recognize that what we create and say also has the potential to positively shape the way the world sees us and our ideas.

New avenues of patient contact. The increased visibility of physicians in social media creates the appearance of increased availability. Consequently, patients will occasionally reach out to get their immediate health issues addressed, and, while they may be offering implied consent by initiating the dialogue, Twitter and Facebook are poor formats for one-to-one health-related discussion. Beyond the fact that everyone’s listening, it is effectively impossible to integrate a Twitter exchange into a patient’s medical record. I have also found that patients often don’t fully understand privacy settings on the applications that they use.

When approached by patients on any kind of social media I immediately take the conversation offline and do my best to resolve the problem. I try to keep in mind that applications like Facebook are the primary form of communication for some patients, but I usually try to educate them on the potential pitfalls of public disclosure of personal health information. In my experience, patients are always understanding of the limitations of social technology. Finally, I document my encounter in a phone note, making it very clear that it was the patient who initiated the contact.

Our obligation to participate. I might finish with the suggestion that as physicians we have an ethical obligation to be involved with dialogue and the creation of health-related content online. Sound reasoning, good clinical information, and evidence-based thinking need to be part of the information stream. And doctors could change the way the world thinks if they would only get together to help create the information that patients see. Consider, for example, the issue of vaccines and autism. If you search for these subjects on Google, you will find the first two pages of search results contain antivaccine propaganda created by a loud, socially savvy minority. The American Academy of Pediatrics has 60,000 members. If every AAP member wrote a myth-dispelling blog post just once a year, Google would be ruled by reason. The medical community has the capacity and power to put good information where our patients seek it—we just need to make it a priority.

As health professionals we have to start looking at this from the perspective of opportunity, not risk. Collectively, we have the capacity to harness the most powerful communication medium since the printing press. We can influence ideas about health. We can change the way our profession is viewed. This is where the patients are, and it’s where we should be as physicians.

Concerning Dr. Baker and her handling of “theGrouchyMD,” the direct approach to her fellow resident is the best immediate course of action. As Dr. O’Connell doesn’t appear to see any problem with what’s she’s doing, the question then centers on Dr. Baker’s obligation to go further. And how we define “going further” is unclear; the boundaries of physician conduct in the online space have not been clearly defined. It should be understood, however, that if these stories were to be somehow connected with the patients they describe, those patients could be harmed and the career consequences for Dr. Grouchy could be severe. Anything that helps Dr. Grouchy understand the risks should be seen as an effort to help her maintain a healthy professional future.

Bryan S. Vartabedian, MD, is a pediatric gastroenterologist at Texas Children’s Hospital/Baylor College of Medicine in Houston. He blogs at 33charts.com.

Commentary 2

by Emily Amos and Jay Baruch, MD

In this case about a physician blogger, tension arises between online communication and professionalism. While there are parts of the blog that most doctors can relate to—the “war stories,” feeling overworked, a desire to provide sensible medical information—there are also parts that stand out as potentially problematic, like Dr. O’Connell’s “need to vent” or the fact that her identity can be teased out from context alone.

For this case commentary, we will provide a working definition of medical professionalism and address how this case bumps up against the definition. We will discuss differences between conventional print media and blogging, and propose a set of guidelines for physician bloggers to encourage responsible Internet use.

Professionalism

Medicine has always had to adapt to new technology, and the Internet is no different [1]. It represents a new forum for patient-doctor interaction and a new arena in which to test our notions of what it means to be a professional and a physician.

Epstein and Hundert define professional competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” [2]. Herbert Swick suggests that medical professionalism is a set of behaviors, including demonstration of humanistic values, commitment to accountability and reflection, adherence to high ethical and moral standards, and subordination of self-interest [3]. Using these definitions, we can pinpoint some of the controversial features of Dr. O’Connell’s blog, and why Dr. Baker might be concerned about her colleague’s online persona, theGrouchyMD.

Why Blog?

Several physician authors have made careers writing narrative fiction and nonfiction for a lay audience through standard editorial and peer review processes. The time-consuming work of revisions encourages thoughtfulness and reflection. The scrutiny and rigor of the editorial process imparts a sense of legitimacy to the book in the eyes of the reader.

Recently, blogging has emerged as a dynamic, powerful tool for online communication and community building, and many physicians have taken up blogging as a way to tell their stories [4]. Unlike academic journals and popular media, the strengths of blogging lie in its accessibility. A democratizing force, blogging allows anyone with an Internet connection to have a say at the click of a button, without editorial barriers. Blogging allows physicians to express thoughts and emotions that might be less prevalent in traditional medical literature. Doubts, fears, frustrations, and disappointment are sentiments that live in the shadows in a profession that values decisiveness, altruism, and boundless compassion.

Blogging as a medium of expression does have a downside, of course. Ease of publication, a fundamental strength of blogging, can also be its Achilles’ heel. Passionate, raw emotion that might feel so necessary to articulate at the moment can lead to regret, or worse [5]. Blogging about medicine and health care as a physician requires restraint and self-editing, not unlike the self-monitoring expected of physicians with respect to ethical conduct [6]. In addition, the lack of a structured, recognizable editing body can undermine the perceived quality or reliability of content published in an informal setting like a blog.

In her writing, Dr. O’Connell is utilizing a divisive feature of blogging: writing anonymously. Through more traditional publishing routes, physician writers take responsibility for their work. Blogging, by contrast, allows authors to determine how much of their true identity they wish to reveal. Medical professionalism requires a degree of accountability from physicians, and, while the protection of anonymous blogging permits frankness and candor, it also implies that the author does not want his or her real identity entangled with the stories being shared online [7]. Dr. O’Connell is using her alter ego, theGrouchyMD, to say “pretty edgy things about the hospital and the residency,” and it is unclear whether she would make similar statements were she signing her real name.

Responsible Writing and Venting

Physicians are legally and morally responsible for maintaining patient privacy [8]. Physician writers must balance their responsibility and obligations to patients with their duty to readers. When Dr. Baker confronts Dr. O’Connell, the latter defends herself by saying “I just need to vent.” What is this need, and is it so important that it subordinates the patient’s interests?

Dr. O’Connell defends her writing on the grounds that changing names and identifying information relieves her of wrongdoing. Can an individual patient be de-identified completely? The context of her storytelling provides enough evidence, narrative fingerprints, that those familiar with the events could extrapolate the real identities of the people involved. It is evident from Dr. Baker’s quick discovery of theGrouchyMD’s identity that Dr. O’Connell’s stories pose a potential threat to her patients’ privacy.

Another argument holds that what matters is not whether a patient may recognize herself, but rather that the physician took information obtained in a confidential relationship and used it for personal ends. De-identification doesn’t change the moral breach; it only reduces the physician’s risk of being caught.

The stakes are high for physician writers, who represent not only themselves but also their practice and profession. A physician’s blog is more than a personal journal in the public domain, because readers are also patients [1]. When a physician blogs about a patient encounter, that narrative weaves itself into the public perception of doctors as a whole and can directly impact patient care. Physician writers must be cognizant of their influence and mindful of the potential for harm as a result of their actions.

A negative portrayal of the patient-doctor relationship may cause readers who identify with the patients in Dr. O’Connell’s stories to question their relationships with their own doctors. When Dr. O’Connell criticizes a 53-year-old patient for seeking fertility treatments as “selfish and irresponsible,” she creates a rift between herself and older women pursuing pregnancy and possibly between those women and their doctors—they may worry that their physicians judge them in the same way. Dr. O’Connell also misses an opportunity for self-reflection when Dr. Baker approaches her. She fails to see that her criticisms of older women seeking fertility treatments—selfishness and irresponsibility—could be leveled against her and her blogging.

The accessibility of blogs puts physician writers in a position to have widespread positive impact. Bloggers who represent the best of the medical profession reflect well on everyone in a white coat. Online forums allow physicians to engage a wide audience, where they can dispel misleading or false medical information, participate in discussion of current issues in health care, and shed light on certain aspects of medicine from a physician’s perspective.

Blogs can also be a humanizing element for physicians, a way to connect with people outside the confines of the hospital. In a survey of physician bloggers, the most commonly reported reasons for blogging included sharing knowledge or skills, influencing the thinking of others, and creative expression [9]. Dr. O’Connell identifies these as motivations for her own blogging, saying, “It’s really useful for people to get sensible general advice,” and sees her physician-authored blog as a way to counteract “whatever junk is out there on the web.” Here, Dr. O’Connell is evincing professional competency, using her technical skills and knowledge for the benefit of her readers. By providing only general medical advice, she is reaching out to those in search of medical information, without venturing into the ethical gray area of online diagnoses [10].

As theGrouchyMD, Dr. O’Connell illustrates both the power and the pitfalls of physician blogging. She is sharing the truth about her experience as a doctor, but treading roughly on patient privacy. She is providing reliable medical information to a large audience, but may be alienating some patients with her cutting commentary. If we were in Dr. Baker’s shoes, what could we offer Dr. O’Connell as a touchstone for appropriate Internet use?

How to Responsibly Use the Internet

Blogging has enormous potential to enrich and strengthen patient-doctor communication if used judiciously [11]. We propose the following guidelines for physician bloggers:

  • First and foremost, always employ the Golden Rule of the Internet: if you wouldn’t say it in person, don’t say it online.
  • Question intent: if publishing a story will benefit only you, the author, consider keeping it to yourself. A fine line separates thought-provoking and inflammatory commentary, and a narrative that is personal is not necessarily insightful.
  • Keep it clean: as a physician in the public eye, you represent not only yourself but also your profession and any affiliated institutions.
  • Care for your patients on the page: you are responsible for their well-being even when they are not physically in your presence.


References

  1. Dyer KA. Ethical challenges of medicine and health on the Internet: a review. J Med Internet Res. 2001;3(2):e23.
  2. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226-235.
  3. Swick HM. Toward a normative definition of medical professionalism. Acad Med. 2000;75(6):612-616.
  4. Lagu T, Kaufman EJ, Asch DA, Armstrong K. Content of weblogs written by health professionals. J Gen Intern Med. 2008;23(10):1642-1646.
  5. Saltzman J. Blogger unmasked, court case upended. Boston Globe. May 31, 2007. http://www.boston.com/news/local/articles/2007/05/31/blogger_unmasked_court_case_upended/. Accessed June 21, 2011.
  6. Kassirer JP. Pseudoaccountability. Ann Intern Med. 2001;134(7):587-590.
  7. Berger E. Emergency medicine in the blogosphere: the irreverent wit of the specialty’s unofficial voice. Ann Emerg Med. 2007;49(5):612-614.
  8. American Medical Association. Patient physician relationship topics: patient confidentiality. http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/patient-confidentiality.page. Accessed June 7, 2011.
  9. Kovic I, Lulic I, Brumini G. Examining the medical blogosphere: an online survey of medical bloggers. J Med Internet Res. 2008;10(3):e28.
  10. Knapp JE. Setting limits is the key to working online: How far should you go in talking to patients looking for advice at your web site? ACP-ASIM Observer. April 1999. http://www.acpinternist.org/archives/1999/04/limits.htm. Accessed June 21, 2011.
  11. Boulos MN, Maramba I, Wheeler S. Wikis, blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education. BMC Med Educ. 2006;6:41.

Emily Amos is a third-year medical student at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, where she is in the scholarly concentration program in medical humanities and ethics. She received her undergraduate degree in public health from the University of Washington in 2006 and spent three years researching malaria vaccine development before starting medical school.

Jay Baruch, MD, is an assistant professor of emergency medicine at the Warren Alpert Medical School at Brown University in Providence, Rhode Island, where he also serves as director of the medical ethics curriculum. He is the author of a collection of short fiction, Fourteen Stories: Doctors, Patients, and Other Strangers (Kent State University Press, 2007). His academic interests include pragmatic medical humanities.

AMA Code of Medical Ethics’ Opinions on Confidentiality of Patient Information, July 2011

The Case History and Deferred Pain, July 2011

Case Studies and the Therapeutic Relationship, July 2011

When Doctors Pick up the Pen—Patient-Doctor Confidentiality Breaches in Publishing, July 2011

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.