Doctors Telling Their Stories Online – A Bridge Too Far?

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Anne Marie Cunningham has an excellent post on her blog today on physician burnout and it raises an interesting question.While we encourage patients to tell their stories through blogs and other social media sites, is it appropriate for doctors and other healthcare professionals to follow suit?

Cole and Carlin (2009) write in the Lancet, that burnout is “also a euphemism for what many physicians experience as a crisis of meaning and identity”. One of the solutions is for doctors to be able to tell their stories and to be compassionately and non-judgementally listened to. Can social media have a role in this?

It’s an interesting question and while Anne Marie cites Jonny Tomlinson’s blog and his latest post on the impact that loneliness can have on patients as a positive example, she also points to the satirical The Moderate Doctor as one that raises questions about the appropriateness of doctors using social media.

The Moderate Doctor is a new website based on The Rules:

The Rules have come together to try to identify some of the difficulties we face as doctors during the consultation. They have helped me identify some of the blocks and frustrations that we may all face when consulting-whilst at the same time trying to acknowledge the patient’s agenda. The difficult bit is recognising that and still providing good, effective medical care.

This all seems quite laudable but the problem as identified by Anne Marie is that the site appears to be aimed at ” bonding with other doctors through joking about their patients”.  However, Anne Marie writes that it wasn’t clear that the focus of the joke was the doctor and that made some people feel uncomfortable.

Screenshot Wishful Thinking In Medical Education

Screenshot Wishful Thinking In Medical Education

Perception Is Reality

In online social networks, the lines between public and private, personal and professional are blurred. The issue here is one of perception and while we encourage doctors to share their human side and their personality, those who do so also risk exposing themselves to accusations of arrogance and lack of empathy. While Dr Moderate’s blog may have been tongue in cheek and intended for an audience of like-minded doctors,  what you publish online is widely accessible and also open to patients to read, comment and form their own opinions on.

I was struck by a comment on Anne Marie’s blog which summed up what many patients will have thought reading The Moderate Doctor blog:

I noticed on Twitter that many doctors think that writing The Rules is an acceptable way to behave, using the usual bully’s tropes “It’s only a joke” and anyone who has a problem with The Rules “lacks a sense of humour”. One day these doctors too will be sick, vulnerable and in need. Let’s hope for their sake that they don’t encounter a Dr Moderate in their time of need.

In the recently published RCGP social media guidelines it is noted that one of the risks associated with social media participation by doctors  is the risk of engaging in behaviour which could be perceived as “unprofessional, inappropriate or offensive by others” .  While Anne Marie writes that Dr Moderate doesn’t breach any  guidelines with respect to breaking patient confidentiality, I wonder does it breach a more intangible code of professional ethics? I would love to hear your thoughts on this discussion. For me it highlights that we still have a way to go when it comes to defining professional use of social media.

photo credit: caricaturas via photopin cc

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31 thoughts on “Doctors Telling Their Stories Online – A Bridge Too Far?

  1. Hi Marie,

    THANK YOU for this. I am all over this issue!

    Just yesterday, I read a tweet by Dr. Sujay M. Kansagra – known as DrK or @medschooladvice on Twitter – which simply read:

    “That awkward moment when the surgery is over, and the scalpel is missing.”

    Responses to Dr. K’s brilliantly witty and apparently hilarious posting were distressing, ranging from “LOL” to this gem from a person called ER Doc – ‏@bigblast who wrote:

    “Or when u realize that the scalpel is missing and u don’t give a fuck”.

    Comments like this (on TWITTER, which means they’re out there for THE WHOLE WORLD to see) beg the obvious question: are these docs burned out, or just idiots? If they are burned out, my advice would be to, please docs, just shut up, go find another job, and stop spewing your toxic “humour” over social media to the rest of us who don’t have the option of not being patients at the mercy of burnouts like you.

    Dr. K’s tweet resulted in 64 retweets and 47 ‘favourites’. This guy has over 46,000 Twitter followers; a quick browse through his list of followers reveals most are medical students.

    What does this say about the people we patients are trusting to touch our bodies and make us better? Or worse, about the young students who will one day fill that role, who have grown up updating their Facebook status about their every waking moment, who have never had an unexpressed thought, no matter how mundane or inappropriate or downright stupid?

    My own Twitter response to DrK’s oh-so-cleverness:

    @HeartSisters “As a dull-witted heart patient, having trouble figuring out why this is even remotely funny. #ptsafety = no laughing matter”

    Where, I wonder, are all the voices of OTHER doctors even remotely concerned about their peers who cross the line like this on social media, entertaining doctors while horrifying patients? Or are there any?

    Only one doctor seemed to opposed DrK’s statement on Twitter. Dr. Matthew Siuba, an internal medicine/pediatrics resident in Michigan – ‏@msiuba – wrote in response:

    “Unsurprising coming from an account known for twitter’s version of “diarrhea of the mouth”

    With docs being urged to join the universal lockstep march towards embracing social media, I suspect many – like the hypertweeter DrK – simply do not ‘get’ those guidelines urging docs to avoid “engaging in behaviour which could be perceived as unprofessional, inappropriate or offensive by others.” I wrote about this a couple years ago in “Why Some People Should Avoid Social Media Completely” – http://ethicalnag.org/2011/08/15/friday-faux-pas-social-media/

    Thanks so much for bringing up this important subject. I’m relieved to know it’s not just me who cringes at this trend, and I’m truly dismayed at the future of med students learning from the likes of DrK.

    regards,
    C

    • Humour is notoriously difficult. The ‘joke’ about the scalpel is obviously about the doctor and his competency. I’m not a surgeon but it probably is a major fear to do something like this. Maybe people do cope with laughing about it. Maybe the laughter is a good thing.

      Laughing at patients rather than with them is a different matter. We have to be able to laugh at ourselves.

  2. I think that Dr Moderate is thinking over what his intended audience was. He very much did want this to be accessible to patients so it wasn’t intended for just a group of like-minded doctors.

    I don’t think that voicing difficulties dealing with expectations is unprofessional. I’m not sure that it was inappropriate either. It certainly might be offensive to others. But I’ve often been told that no-one has the right not to be offended. I have mixed thoughts on that. Offending the powerful might be OK, but the weak and vulnerable, that’s not on.

    Dr Moderate probably did expect that others would read what he had written and not find it funny, or disagree, but I think he was taken back by the force of the response.

    Openness and transparency means that we don’t just present manicured profiles to the public. We have to be prepared to admit that all is not well in our communities and to try and come up with solutions together. It isn’t going to be comfortable but work which is worth doing usually isn’t.

      • PS Nobody is saying (I think!) that docs ought not to be allowed to vent, spew, rant just like those in any other profession. There’s a big fat difference, however, between venting, spewing, ranting or telling in-jokes around the water cooler – and posting them online for the entire planet to read. This is medicine we’re talking about, so chances are excellent that the persons being poked fun at are indeed those “weak and vulnerable” you mention, Anne Marie.

      • So we shouldn’t encourage doctors to talk about the messy stuff even under a pseudonym? How about patients and other doctors and other professionals actually try and help people sort these problems out? If all of this conversation is to happen in a closed space with only doctors participating then I think we will lose out. If people are going to poke fun at the weak and vulnerable then let them do it in an open space where we can at least challenge it.

  3. Hello Marie,

    An important topic you have brought to light. I recently read some disappointing tweets from a doctor at a conference taking the “shock doc” Twitter approach – and unfortunately, he is also coaching other doctors on the use of Twitter. Some doctors are letting their belief that they need to be entertaining on Twitter overtake common sense –and a sense of humanity.

    On the other hand, you have doctors – like @storkbrian, @RonanTKavanagh, @SeattleMamaDoc, @hjluks and many others – who use social media for good, patient education, sharing their experiences with health technology, and focus on their community.

    • If we see something we don’t like we should challenge it. But we shouldn’t set hard and fast rules about things that are inappropriate apart from those that we have help as professional values since the start. I don’t think there is one right way to do social media. If there was it would of course be mine ;-)

      • Well actually now that you mention it, you are a good example Anne Marie ;-) I am not coming down hard on either side in this discussion – I just want to highlight that social media of which I am a huge advocate in healthcare is not without its risks, one of which is how you are perceived professionally (am wearing my PR consultant’s hat here).

  4. I am so grateful to all of you who have taken the time to join this conversation – it seems there is a divide between doctor and patient perception of what constitutes professional behavior on line. Interestingly when I joined the Twitter chat for the launch of the RCGP guidelines one of the issues put forward was whether patients needed to be given guidelines on how to interact with docs online. So much yet to debate in the arena of health care social media!

    • I don’t think this is a doctor-patient divide. Many doctors have said that ‘water cooler’ stuff should stay there. And many patients have said that they’d rather know what doctors are really thinking. My belief is that it is much too simplistic just to say that important issues should not be raised in public spaces. But if we start the conversation then everyone has to be prepared for their views to be in conflict with others, and to have to do quite a bit of work to resolve them. Messy problems won’t have straight forward solutions.

  5. I agree that it is too simplistic to reduce it to a black and white issue Anne Marie – which is why I posed the headline as a question. I am genuinely interested in the discussion from both the patient and the doctor point of view. The start of your post on your blog begins by highlighting the issue of physician burnout and you ask a good question – where can docs go to to tell their stories. It is a question that should be addressed, but equally it needs to be borne in mind that doing so on a public platform will invariably affect patient perception of physicians – which has the potential to be both a good and a bad thing. Thanks for raising the issue – your blog is always a challenging and informative read.

  6. Absolutely agree, Ann Marie, that there is no “one way” to use social media!! My study on personality types on Twitter shows that many people engage differently, and it is in understanding these differences in people and engagement that is important. However, some “personalities” are not very attractive. Accumulating over time, doctors’ digital footprints will reflect who they really are. Patients will increasingly be using this information to choose their physicians.

    • In this case though Dr Moderate was raising this issue under a pseudonym. To my mind if you feel you are struggling or vulnerable, even if a doctor, then the use of a pseudonym is OK. It creates a safe(ish) space to discuss a topic knowing that it will not impact on your digital footprint. Of course by expressing his interest in watches, cycling and coffee, Dr Moderate has maybe made himself a good deal more identifiable that he might have been- always a risk.

  7. @amcunningham: “If all of this conversation is to happen in a closed space with only doctors participating then I think we will lose out. If people are going to poke fun at the weak and vulnerable then let them do it in an open space where we can at least challenge it.”

    I disagree, on so many levels. There are also clearly a couple of separate issues here: 1. doctors or other health care professionals experiencing burnout and 2. using social media inappropriately.

    How can one determine what’s “inappropriate”? It’s about respect. “Think like a patient” is what I recommend.

    Before my heart attack, I worked in hospice palliative care for many years, where dark humour was common among staff, as it is in every hospital ward. But everybody I worked with was patently aware of how “inappropriate” it would be to EVER vent or complain or make in-jokes within earshot of the very patients/families who were coming to us for care. No matter how challenging or painful a day could get, we all knew that we need to pick wisely who to vent to, and who never to vent to.

    There is NO downside to docs having these conversations in closed spaces with only their peers participating. In fact, there is significant benefit to safely unloading one’s grief and frustrations.

    But there are many downsides when these conversations go public on social media, for the dubious benefit of patients becoming aware of what their caregivers are going through. ???

    As for openly “poking fun at the weak and vulnerable” being even remotely acceptable, I can only think that you must be having a very bad day and cannot possibly mean that.

    • HI Carolyn,

      I don’t think that poking fun at the weak and vulnerable can ever be acceptable.I could never encourage it. But perhaps I am naive in thinking that we could and should collectively and individually challenge this if it happens in public.

      With regards to appropriate use being acceptable to patients, sometimes doctors don’t think like patients. Sometimes they get so caught up in their own worlds and their own distress that they make judgments that you and I and others might not agree with. That’s where responding compassionately comes in. My own blog post makes the point that one is most certainly not guaranteed a compassionate response in social media because the audience is diverse. Anyone writing in a public space has to be prepared for that. And for the responses.

      AM

    • “There is NO downside to docs having these conversations in closed spaces with only their peers participating. In fact, there is significant benefit to safely unloading one’s grief and frustrations.

      But there are many downsides when these conversations go public on social media, for the dubious benefit of patients becoming aware of what their caregivers are going through. ???”

      Carolyn, sorry, but as a patient, and definitely not a medic, I don’t agree. I *do* agree that there are risks, and that it needs to be clear that some of the black humour is just that – but for me (and others I know), I would rather know that medical staff can interact with other human beings, despite the nature of their job, including “unloading” to some extent (obviously not with patient details), and including being, perhaps, ‘inappropriate’ with their humour. If it is all kept behind closed doors, you (plural, generically) look (and I may add, often behave) as though you are inhuman automata without an ounce of compassion – so busy hiding your frail humanity (aka actually being a real person) from patients that you should be empathising with.

  8. I will keep this brief. I am quite sure that your medical malpractice insurance carriers and defense team would frown upon this if you as a medical professional ever find yourself faced with a lawsuit. They will pull any and all tweets, blog posts, etc. They can and will be used against you in a court of law. Be smart!

  9. I will make this brief. I am quite certain that the medical malpractice insurance carrier and defense team that will insure and defend you if you are ever faced with a medical malpractice lawsuit would frown upon any tweets, blog posts, etc. especially if they can be read in a negative light. It is not difficult to pinpoint who you are if they really dig. Any and all social media posts can and will be used against you in a court of law. Do not be stupid and keep it within the walls of the office. Pretty simple!

  10. Reblogged this on Medical Malpractice: A Patient's Story and commented:
    Doctors beware! I am quite certain that the medical malpractice insurance carrier and defense team that will insure and defend you if you are ever faced with a medical malpractice lawsuit would frown upon any tweets, blog posts, etc. especially if they can be read in a negative light. It is not difficult to pinpoint who you are if they really dig. Any and all social media posts can and will be used against you in a court of law. Do not be stupid when it comes to your career and keep it within the walls of the office. Pretty simple!

  11. Good points Marie. Dr Moderate made me smile with the publication of the arguably intemperate rules. However, they were prefaced with a health warning. @b12unme responded en passant with patient perspective published on Dr Cunningham’s blog.

    My blog http://maturinuk.com includes personal opinion from my experience as patient and doctor. The internet does permit everyone to engage in discussions about and among professionals.

    It will be a shame if awkward ideas and statements are not allowed to be seen by all. A open and permissive internet is the answer to such uncomfortable writing because the author(s) can be challenged about prejudices. Meanwhile, readers are also challenged – some choose to ignore the uncomfortable stories, others respond with righteous indignation. Yet some engage in thoughtful dialogue because satirical writing often includes grains of truth.

    Please keep the discussion going. Only in this way can human values in healthcare flourish. For example, http://www.humanvaluesinhealthcare.com

  12. Pingback: What Influences Medical Students’ Perceptions Of Professionalism? | Health Care Social Media Monitor

  13. This is a very interesting discussion and it seems to me, there is over-lap here into other professions. As an educator, I would be very wary of engaging in satirical burn-out talk online anywhere with my peers. I agree there are two separate issues here – burnout and social media use by doctors. There are no easy or right answers, but common sense probably needs to prevail here. I am a blogger, too, and I always try to be mindful about remembering that whatever I write about (or tweet about) will be out there for all to see for quite some time. Worth noting perhaps, is that a “problem” with satire is that not all people are able to see it as such. There are consequences to your actions – it pretty much comes back to that doesn’t it? If you’re going to post thoughts, viewpoints, satire or whatever, you have to be prepared to handle the fall-out, good and bad, or else learn to ignore it. Thanks for getting me to think about this.

    • Excellent points, Nancy. I’ve observed in general that those who post anonymously online are far more likely to engage in troll behaviour – sarcasm, satire, disrespect, profanity, lack of any perceptible humanity – than they ever likely would if their own names were revealed.

      Early in my journalism days, no letters to the editor were ever published anonymously. Ever. To do so merely encouraged the trolls to spew forth.

      I’m guessing that one of the reasons you stop and think carefully before hitting ‘publish’ on your blog posts may also have something to do with the fact that your name and photo are clearly there for all to see. Thus you feel personally accountable for what you write and how you say it, and are mindful of who will be reading it. (Doesn’t mean you don’t call a spade a spade – which you do so elegantly and forcefully on your site!)

      Anonymous posters on social media have no such filter.

      This is a far bigger issue than just docs on social media. You can’t unring this bell, sadly, but I’d sure love to see health care professionals with the guts to use their real names online. I suspect many don’t simply because they’d be embarrassed if their patients heard what they’re actually saying.

  14. Honestly I think people need to come off there high horses. Doctors are humans too. And just like the rest of the human race they tell jokes that aren’t that funny. If you want social media to be “appropriate” or “professional” then make your sites that way. If you don’t want to know/you can’t handle how you’re doctor thinks then do not go onto there social media pages. It’s pretty simple.

  15. I suspect a large part of the problem is we all bitch and moan about our jobs and use humour as a stress reliever. The problem is when this moves out of the tearoom and is put in the public domain. It’s the difference between making a joke about a difficult workmate or client/patient to your colleague around the water cooler and putting that same comment in a newspaper.Social media is like putting something in the newspaper but worse cos newspapers are perishable, social media gaffs last a lifetime. Context is key and frankly you’re pretty silly if you can’t tell the difference between an appropriate and an inappropriate context.

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