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.”
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.