Back in college, a friend of mine was seeing a therapist. It was a small school, and the therapist was always in the commons drinking coffee and smoking with the students, including my friend. It was a little sketchy even back then, but she was sure it would end after college. It hasn’t: More than 20 years later, the shrink is all over Facebook. She’s “liked” my friend’s business Facebook page, she frequently comments on the alumni page, and she’s become Facebook friends with other classmates. My friend is not happy that this ex-therapist—someone with whom she shared deeply personal issues from a difficult time in her life—has taken advantage of easy online access to her, even if it’s virtual. Old classmates you never liked all that much lurking on your page are one thing, but a medical professional who knows your inner secrets is a whole other level of invasion. In my friend’s words: It’s creepy.
Creepy, maybe. Unprofessional, sure. But should this kind of online behavior be reported to state medical boards—the agencies responsible for licensing doctors and disciplining those who behave badly? Situations like this are more than a blip on the radar: According to a recent research letter in JAMA, more than 90 percent of state medical boards have received at least one complaint of bad online behavior. The researchers (my husband was one of them) catalogued some online slip-ups, including inappropriate patient communication online; prescribing via the Internet without knowing the patient; lying about credentials; violating patient confidentiality; making derogatory remarks about patients; using discriminatory language or practices; and appearing intoxicated in photos. The complaints came from patients, family members, fellow physicians, and other medical personnel. "Like everyone else, doctors sometimes stumble in their online behaviors and make mistakes in judgment about content they post; they think they're doing nothing wrong but, unfortunately, the disciplinary responses can be a big deal," Dr. Ryan Greysen, the lead author of the study and an assistant professor of medicine at UCSF, told me. Indeed, more than one half resulted in suspension, revocation, or limitation of the physician’s license.
Here’s the problem: Doctors are learning social media nuts and bolts by trial and error. As recently as 2010, only 10 percent of medical schools had social media policies, according to an article in Medical Education Online. Some—like those of the Mount Sinai School of Medicine—go beyond the general guidance offered by most by including a colorful list of concrete examples of what not to do, such as posting a photo of a baby discharged from the hospital without getting the parents’ permission. Other guidelines, such as those put out by the American Medical Association, advise doctors to be careful when posting and to always maintain patient privacy, but these recommendations—instead of popping up as screen savers on exam room computers as regular reminders—are buried in websites.
As a physician, I understand the temptations to post one’s opinions online. I did my medical residency in the mid 1990s, and, every night (or morning, if I’d worked a night shift), I wrote in my journal. It was a place to unload my thoughts about working in the hospital, the sickness, the stress, the lives wracked by illness, the daily emotional wallops. When email came around I was in heaven. Finally, I could share these stories of anonymous patients and get some reaction—shock, empathy, fascination, or solidarity. I stopped after awhile; one friend told me he cringed when he read my description of a dying man in the ICU and pointed out what was obvious to him, but not, at least initially, to me: That email and patient privacy didn’t go well together, that there’s something sacrosanct about the secrets you learn while caring for a person at his most vulnerable, and that many of these stories shouldn’t see the light of day without the patient’s blessing. Imagine, for example, reading a doctor’s blog and suddenly realizing that the patient being described was your mother. If she’d given the doctor permission, that’s one thing; if she hadn’t—and even if the patient was anonymous—you’d probably be outraged.
In 2012, with potentially hundreds of friends reading their Facebook posts and countless strangers receiving their Twitter feed, it’s even easier for doctors to push the boundaries. “There are many good physicians who don’t mean to slip up on line; they just aren’t careful enough,” Dr. Greysen said. In other words, it’s not the obvious no-noes that are the issue (posting a patient’s name or diagnosis online; asking patients out via social media), but the fuzzier ones, like describing patients in just a little too much detail without their permission, friending patients on Facebook, or like my friend and her ex-shrink, inviting oneself into virtual spaces that should be off limits. Among my own Facebook friends, many of whom are fellow doctors, quips about interactions with patients are usually funny and gentle, but there are occasional sarcastic and even nasty comments.
So how do doctors learn what’s okay to tweet and blog and post? According to Dr. Robert Centor, who has blogged for almost a decade, it’s a combination of common sense and thinking before writing. Before Dr. Kimberly Manning started blogging about caring for patients and teaching in a large public hospital a few years ago, she studied the 18 unique HIPAA patient identifiers—specific details in the medical record that can identify a particular person, such as name, date of birth, address, full-face photos, social security number, and email address—and decided that since neither she nor her hospital could be anonymous, she would not only change some details of her patient’s stories but also ask their permission to share them. But not all doctors are so careful.
Most state medical boards now allow you to object to a doctor’s behavior through a “file a complaint” hyperlink on the main page. (Here’s one.) Some include checklists of examples of reportable bad behavior—but only office-based bad behavior (such as prescribing inappropriately, substance abuse, sexual misconduct, substandard care, misrepresenting credentials, discrimination, and drug diversion). If you’re looking for guidance about online violations, fuhgeddaboutit.
But here’s the good news: That guidance may be just around the corner. Last week, the Federation of State Medical Boards released new guidelines for doctors about the proper use of social media and social networking: from protecting patient privacy online and avoiding requests for online medical advice to imploring doctors not to forget that one little click can catapult any online post—secure or not—into the very public domain of cyberspace. The guidelines provide some striking examples of unacceptable online behavior, too: a urologist tweets an opinion with disrespectful language that’s seen by patients and colleagues; a patient reads a doctor’s blog that refers to another patient as “lazy” and “ignorant”; a patient is asked out by her own doctor, who comes across her profile on an online dating service. Let’s hope that the FSMB creates a user-friendly version for patients, and that doctors pay attention. If we’re lucky, these sensible guidelines will go viral.