On Monday night, Dr Bryan Vartabedian, a pediatric gastroenterologist in Texas, wrote a blog post about physician behavior on Twitter. In the world of health and social media, it’s caused a near nuclear explosion of thought, an outpouring of opinion, and most importantly a much-needed discussion. Discourse is perfect for progress.
I think about this all the time.
In the post, Doctor V called out an anonymous physician blogger and tweeter, (@Mommy_Doctor), on her tweets about a patient suffering from an embarrassing and painful medical condition. Nearly 100 comments later and numerous other blog posts, physicians and patients are openly battling and exchanging perspectives.
I wonder, what do you think? I rarely write about patients directly. More, I write about what I learn from patients. I never want a patient or family member to stumble upon anything I write and wonder if I’m writing about them. When I have written about patients, I have asked permission and even then, waited for a period of time before writing about them to avoid the time-stamp the internet provides.
The reason many physicians don’t author content online is their concern about privacy. Their hesitancy is admirable. In our own time, I suspect most of us will end up communicating online, but it will be at different times (decades) for each of us.
Some history: I have had one tweet that I’ve taken down after a physician called it a HIPAA breach. It wasn’t (I even consulted with my colleagues in bioethics) but I swiftly took it down. I’m not here to be devout and certainly not trying to stoke the fire. I was thankful for the feedback and remain pleased I took that particular tweet down. I talked with the family involved immediately. I learned a great deal from a peer’s observation. We are dependent on our wise and smart community to help guide what we do for our patients, particularly online.
I really wonder what you think about this. Will you read Doctor V’s post and let me know? My comment on Dr V’s post is number 98:
When I speak about physician use of social media, I take the stand against anonymity for physicians. Simply put, remaining anonymous protects the person/physician tweeting, not the patients, or the profession for that matter.
Like many have said before, we need to aim above HIPAA and we sincerely need to consider how our content and voices over social media reflect not just the respect of our profession, but trust in what we do. Compliance and patient outcomes depend on it. Consider what distrust in physicians does to vaccine hesitancy, for example. It has public health ramifications (118 measles cases since January).
You might also have to step back from the democracy of opinion here. It’s not the majority that matters (how many people chime in and state which side of this particular tweet stream they support). I’d say if one or more individuals believe your content is a breach of privacy and professionalism, you ought to step back, consider taking it down, and revisit your oath.
Martin Young says
I blog to share what it is like being a doctor in a way that I hope promotes understanding, educates, informs, builds bridges, and corrects inequalities, with a target audience that includes doctors and patients.
My goal is to build trust through transparency. Joking about patients and cases in social media does nothing to build trust.
Were you given the luxury of being a private notice by the someone who felt you violated HIPAA by your tweet? or did they make it a very public issue? While I agree with much of what Dr V wrote, I think he should have made an attempt at a private discussion first.
Wendy Sue Swanson, MD says
It was private. Actually, the particular physician (I don’t know personally) contacted the hospital with concerns about my tweet because all of my tweets stream on my blog which is part of the hospital website so very much public and somewhat amplified. I don’t know if the doc is on Twitter. But he saw the tweet on the blog and because the physician had access to private information about the patient, he knew who I was talking about….so to him it felt like a privacy breach.
Bobby Ghaheri, MD (@DrGhaheri) says
I was one of the MD’s involved in this debate last night. First off, I think Bryan achieved his goal: beginning a discourse on the subject, which is sorely needed. Last week, I gave a talk at the 140 Characters NW conference on the role of MD’s in social media and touched on these kind of issues.
However, I take exception to his methods. He rides the high horse of physician professionalism, yet publicly calls out a colleague without having the decency to contact her in private first? And then, when he is criticized, he immediately unfollows those who criticize him on Twitter.
Social media is NEW to medicine. You cannot apply old standards of ethics and professionalism to this media. It doesn’t work. The generation of people on Twitter have a different concept of privacy and what’s “appropriate”. Were some of her comments poorly chosen? Yes. Did she need to be publicly humiliated for it? Absolutely not.
JRichardson, MD says
Absolutely spot on. Thank you for posting and commenting:
“…voices over social media reflect not just the respect of our profession, but trust in what we do.”
I was involved in this debate today morning.
Let us look at a few facets of this story–
1) Does one need to keep a Doctor profile if the intention is not to help patients with hcsm? One can always go ahead with a personal profile.
2) Why does have to be anonymous with a doctor profile if the intention is to help patients? How many patients will really trust you with an anonymous profile?
3) Why use social media to poke fun at patient’s suffering? In fact it is a great avenue to learn from patients. To listen to something that would otherwise be untold.
I am sure, the debate would continue. Hoping to learn from it……
Bryan Vartabedian says
Dr. Ghulari – your concerns are centered on the rights of the doctor. My concerns are centered on the concerns of the patient. What you think, what I think or what Mommy Doctor thinks is irrelevant Once you consider what it would feel like to read this as the patient you might start to see things in the most appropriate perspective.
And evidently you know very little about me. I follow/unfollow various folks every day based on how their feed meets my needs in the near short term. While Twitter may be a party to you, it is an inbound tool for me. And for the record, you have been quite critical of me on this matter and I will continue to follow as long as your information is helpful to me.
Nate Osit says
I was also involved in the debate last night, and agree with your take here. I would only add that I feel physicians should strive to be respectful at all times, not just when they’re publicly sharing their thoughts. Someone brought up the question of whether these types of comments would be acceptable at a dinner party, and my take was that no, we should respect patients wherever we are. By accepting these attitudes in private, it could reinforce disrespectful attitudes towards patients which inevitably will leak into how someone interacts. As a healthcare community; of doctors, nurses, administrators, IT, and most of all patients, we should strive to be better. Because words can hurt, and in the end we’re all in this together.
D. Chapman, MD says
Three issues come to mind:
1. The tweets were unquestionably inappropriate. Especially, their public nature.
2. Is there an age related difference in the opinions on this issue? Will younger or future physicians see this issue differently, since they have grown up posting every aspect of their life on youtube, facebook and twitter every five minutes.
3. The issus of anonymity has two side. It can cause the commenter/blogger/tweeter to feel free to say things they might not if their identity was tagged to it. However, sometimes, when commenting or blogging on controversial issues there can be safety issues and remaining anonymous can be important. I can think of one case of a blogger (Dr. David Gorski) who had a campaign started to get him fired for blogging about the anti-vaccination movement.
However, I don’t believe that this exception applies to the tweeter in this case.
Linda Pourmassina, MD says
I have a particular interest in the doctor-patient relationship and the things that break this down (slowly and subtly). Mommy_doctor’s tweets ended up being an unfortunate example. Our quandary, as physicians, is that the public simultaneously wants their doctor to be human and to be perfect. This is similar to when a child wants her parent to be a more like a friend. And as doctors or parents, we also want to be those things, too.
But there are ways to be both. We should at least strive to be perfect with regards to professionalism and ethics (after all, we are not perfect in the actual scientific practice of medicine). I know my own personal doctor is not perfect, but I expect a certain level of professionalism and respect from her and trust that she wouldn’t be casually discussing parts of my healthcare on a public forum. I completely agree with Dr. Swanson when she says “we sincerely need to consider how our content and voices over social media reflect not just the respect of our profession, but trust in what we do.”
Until we experience what it is like to be in a vulnerable position, we do not know the importance of having this level of expectation from our physicians. But we should try anyway.
As a side note, I disagree with Dr. Ghaheri’s comment about professionalism. I am pretty young and don’t consider standards of ethics and professionalism old or new. They shouldn’t be adjusted to accommodate a medium of technology.
Melissa Arca, M.D. says
Great post Dr. Swanson. I too, think of this all the time now. I did read Dr. V’s post and thought of what an unfortunate incident this was , but like you, feel this is something we can all learn from.
Whenever I blog, tweet, or post a status to facebook, I always ask myself if what I’m writing will make the parent or patient upset, embarrassed, or violated in any way. Mostly, I shy away from sharing these personal encounters until much time has passed and there’s no way the patient can be identified.
Unfortunately, I think as physicians we do not have the luxury of airing our grievances or funny anecdotes that we encounter. Even anonymously.
Sure I love the MD based shows that do it for us (House, Scrubs, etc) but that’s “fiction”.
This is a great and important discussion for sure.
Meredith Gould, PhD says
I’m fascinated by how this conversation is unfolding, trying to track how individuals respond and how their response(s) reflect education, training, cohort, location in the profession(s), etc. Can you tell I’m a sociologist?
As a sociologist, I’m interested in how digital communities emerge and develop which, I argue, is not all that differently from IRL (in real life) communities. Also similar, are the ways communities regulate members and members self-regulate. This conversation is providing great data.
As someone who has, at times, earned her living as a marketing and PR professional, I’m also interested in how rules of engagement, especially propriety and civility, transport (or don’t) to online interactions. This conversation is providing great data in that domain as well.
As a former therapeutic bodywork practitioner with a private practice specializing in serving clients with incest and sexual abuse issues (referrals primarily from psychologists, social workers and an occasional psychiatrist), I’m always very concerned about confidentiality.
Finally, as someone who works in/around/with faith-based communities, I’m also fascinated to note how all the issues and how they’ve been expressed within the HCSM community are also going on among clergy I follow on Twitter who are realizing that public tweets are just that — public and viewable by congregants who are, in that world, equivalent to patients.
I had to look up what priapism means! I guess using the medical term masks how juvenile the whole thing is. I don’t think we are expecting perfection by expecting doctors to not joke about embarrassing medical conditions on twitter. I would consider this a great violation if it wasn’t anonymous. Then all the ER staff would know who it was referring to. It not so much a violation of privacy but it is a violation of common decency.
It seems to me that doctor_mommy is using social media to socialize with other doctors. Dr V and others are using social media as an aspect of their jobs. You have to allow some space for doctors to just be ‘civilians’ on twitter. Then the response is a social one: dear dr mommy who are acting like an arse and not a professional one.
Got my little one down for a nap and can add: I totally applaud the twitter MDs for policing this sort of behavior. I imagine Dr V would have made a comment if this was a loud exchange in a bar or at a party. HIPAA just doesn’t cover all situations that harm a dr/patient relationship. It’s ugly to imagine an ER Dr who is caring and sympathetic in person turning around and laughing about it because (huh huh) boners are funny. It’s not unlike the vaccine debate actually in that credibility is such an important currency in medicine.
Ryan Madanick, MD says
Your post inspired me to write my blog piece tonight (Anonymity and Professionalism on Twitter: Room to Educate)…Thanks, Wendy Sue!
I’m an attorney in the healthcare regulatory field, and currently I deal almost exclusively with HIPAA issues. I would start by saying that, although post-HITECH HIPAA is gearing up to be a huge scary beast that MUST be taken seriously (multimillion dollar fines for accidentally leaving patient records on a subway train – yikes!), this really does come down to something much more fundamental. Confidentiality of patient information pre-dates HIPAA by a long, long time. Part of the Hippocratic Oath is “whatever in connection with my professional practice or not in connection with it I may see or hear in the lives of my patients which ought not be spoken abroad, I will not divulge, reckoning that all such should be kept secret.” Just because you can now share your every thought and action with the whole world via twitter and Facebook and your blog and whatnot, doesn’t mean that you have ANY right to do the same with your patients’ information. That information is sacred, as it always has been. It is HARD, and it is a responsibility that is unique to certain professions. I have the same burden as an attorney. There have been plenty of times when I have wanted to “decompress” at home or with friends and talk about a client or something that was going on at work, and simply couldn’t. It’s part of the job.
There ARE ways to meaningfully use your clinical experience in social media by generalizing and carefully de-identifying. But you have to be careful. Remember one of the HIPAA patient identifiers is all dates related to the patient INCLUDING DATE OF SERVICE – that means if you talk about doing a procedure on a patient “yesterday” you have just revealed identifiable patient information. It may seem like overkill, but as crazy as it sounds, I have dealt with issues where patients (or people who knew patients) overheard doctors chit-chatting in person or posting on the internet about a specific patient and they recognized the patient – even though the doctors were not using names or descriptions of the patients. Those 18 patient identifiers exist people mathematical analysis has shown that with any of those identifiers in the picture, someone really COULD identify the patient.
I actually think MOST physicians whose practice of medicine pre-dates social media are okay in this area. They have common sense and a healthy fear of (inadvertently) violating patient confidentiality. I have every now and then contacted a physician (privately) when I’ve noticed something like a screen capture of an ultrasound that had patient identifiers on it, but for the most part I see LOTS of docs out there (like you) being responsible. What worries me, are the new docs. The ones for whom tweeting every thought it just second nature, the ones who don’t think anything about putting their entire lives on Facebook. I think it will be much more difficult for them to stop and think about what they are putting out there – because it is just so natural for them to use the internet as a place to have casual conversation.
There are lot of problems with patients that can not discus directly with the doctors you are doing a good job through twitter.