The doctor is onlineDigital patient and clinician cultures

Have you ever Googled a medical symptom? Posted in an online forum before visiting your general practitioner? Used social media to voice an opinion about a healthcare provider or speak about your personal experiences? For many people, turning to the Internet (especially social media) has become a natural way to seek quick answers and discuss medical matters, and the increasing reliance on “Dr. Google” has altered the way that people engage with clinicians.

In addition to changes in Internet usage and communication patterns within patient groups, a large number of clinicians have developed their own digital cultures and communities. In fact, medical communities are extremely active, and tend to make use of a large variety of communication channels. Through personal blogs, Twitter chats (e.g., MD Chat and #hcsm), and professional social media networks like BMJ’doc2doc, clinicians are increasingly talking online.

A 2011 survey conducted by the Canadian Medical Association found that 51% of physicians who responded (of 628) believed that “social media can increase public knowledge about medical issues” and 46% of respondents felt that social media use could also foster “better peer-to-peer sharing of medical information and insights” (which is good news from an altmetrics perspective). However, many within the sampled physician population were also wary of the Internet’s collision with medicine: 44% of respondents felt that social media engagement had little to offer in terms of influences on day-to-day practices, while 80% agreed with the statement that “the use of social media poses professional and legal risks to physicians”.


The rules of engagement and Dr. Anonymous

Fears of breaches in patient confidentiality, reduced professionalism, loss of trust in physician-patient relationships, and various other examples of misconduct have prompted professional medical associations to release guidance and policy documents outlining appropriate social media practices. For the most part, the rules (e.g., see the comprehensive “Social Media Highway Code” from the Royal College of General Practitioners in the UK) can be followed by exercising common sense , but many scenarios are a bit more ambiguous. On 25 March 2013, the General Medical Council published an online document entitled “Doctors’ use of social media”, which outlines a number of rules, including a particularly controversial one on Anonymity in point 17:

“If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name.”

This statement sparked an online debate that was so animated that eventually the GMC stepped in and responded to the concerns about the perceived loss in doctors’ free speech. (Read some of the physician responses: Dr. Henry Woo on Surgical Opinion and KevinMD.comscottishphil 83’s postPeter English’s postAnne Marie Cunningham’s post, and Max Pemberton’s article in The Telegraph. More arguments can be found here.)

Even though the physician anonymity issue was rather divisive within the online community, the whole conversation about the GMC guidance document seemed to indicate that physicians truly value their online voices. There are many different reasons for using one’s real name or a pseudonym, and regardless of which is chosen, it appears that many physicians just want to be able to use online tools to effectively communicate with their peers, patients, and the general public.


Pause before posting

A few days ago, another set of guidelines was released, this time for American physicians: a position paper describing recommendations for physicians’ usage of digital technologies was published in the Annals of Internal Medicine. The guidance document, authored by the American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB), contains comprehensive advice for physicians on how to maintain professionalism online. (The JAMA news blog summarised the points here.)

The following 5 positions are taken from the paper:

  1. Use of online media can bring significant educational benefits to patients and physicians, but may also pose ethical challenges. Maintaining trust in the profession and in patient–physician relationships requires that physicians consistently apply ethical principles for preserving the relationship, confidentiality, privacy, and respect for persons to online settings and communications.
  2. The boundaries between professional and social spheres can blur online. Physicians should keep the 2 spheres separate and comport themselves professionally in both.
  3. E-mail or other electronic communications should only be used by physicians in an established patient–physician relationship and with patient consent. Documentation about patient care communications should be included in the patient’s medical record.
  4. Physicians should consider periodically “self-auditing” to assess the accuracy of information available about them on physician-ranking Web sites and other sources online.
  5. The reach of the Internet and online communications is far and often permanent. Physicians, trainees, and medical students should be aware that online postings may have future implications for their professional lives.

Compared to the GMC’s social media guidelines, the ACP and FSMB paper spawned relatively little controversy, although some people found the text to be rather laborious. (This Forbes article described the paper as “unreadable”. Perhaps a more concise version of the positions could have been included, along the lines of the Mayo Clinic’s “12-Word Social Media Policy”.)

Annals of Internal Medicine | Online Medical Professionalism.Some good items here but IMO too many don’ts #hcsm

— Robert S. Miller, MD (@rsm2800) April 14, 2013

In an excellent blog post, Alan Regenberg (from the Johns Hopkins Berman Institute of Bioethics) argued against position #2, writing that “personal and professional spheres are different but hopelessly entangled”. Instead, he suggested that physicians need to realise the challenges in separating their personal and professional personas online, and act appropriately in both spheres.

The guidance document certainly seemed to reach its intended audience. According to Altmetric data, the paper was widely shared by tweeters originating from the USA (47%) – these tweeters were mostly individuals, but a few influential tweets were sent out by some North American professional associations as well, including the American College of Physician Executives, the Pennsylvania Academy of Family Physicians, the North American Spine Society.

Given the current level of online patient engagement, as well as the growing use of social media and blogging in clinicians’ circles, it’s clear that the Internet will continue to change communication patterns surrounding healthcare. The high amount of attention that the ACP and FSMB paper has received within the past few days demonstrates the strength of social media’s influence on the practice of medicine. Undoubtedly, every social media-savvy physician who has read the article has had to consider his or her own online habits and decide if any changes need to be made. And so, although citations in the scholarly literature probably won’t be expected, the altmetrics indicate that the paper has already been quite influential on its large and highly-social target audience.