AMA Journal of Ethics^®

Case

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.”

Commentary 2

In this case about a physician blogger, tension arises between online communication and professionalism. While there are parts of the blog that most doctors can relate to—the “war stories,” feeling overworked, a desire to provide sensible medical information—there are also parts that stand out as potentially problematic, like Dr. O’Connell’s “need to vent” or the fact that her identity can be teased out from context alone.

For this case commentary, we will provide a working definition of medical professionalism and address how this case bumps up against the definition. We will discuss differences between conventional print media and blogging, and propose a set of guidelines for physician bloggers to encourage responsible Internet use.

Professionalism

Medicine has always had to adapt to new technology, and the Internet is no different [1]. It represents a new forum for patient-doctor interaction and a new arena in which to test our notions of what it means to be a professional and a physician.

Epstein and Hundert define professional competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” [2]. Herbert Swick suggests that medical professionalism is a set of behaviors, including demonstration of humanistic values, commitment to accountability and reflection, adherence to high ethical and moral standards, and subordination of self-interest [3]. Using these definitions, we can pinpoint some of the controversial features of Dr. O’Connell’s blog, and why Dr. Baker might be concerned about her colleague’s online persona, theGrouchyMD.

Why Blog?

Several physician authors have made careers writing narrative fiction and nonfiction for a lay audience through standard editorial and peer review processes. The time-consuming work of revisions encourages thoughtfulness and reflection. The scrutiny and rigor of the editorial process imparts a sense of legitimacy to the book in the eyes of the reader.

Recently, blogging has emerged as a dynamic, powerful tool for online communication and community building, and many physicians have taken up blogging as a way to tell their stories [4]. Unlike academic journals and popular media, the strengths of blogging lie in its accessibility. A democratizing force, blogging allows anyone with an Internet connection to have a say at the click of a button, without editorial barriers. Blogging allows physicians to express thoughts and emotions that might be less prevalent in traditional medical literature. Doubts, fears, frustrations, and disappointment are sentiments that live in the shadows in a profession that values decisiveness, altruism, and boundless compassion.

Blogging as a medium of expression does have a downside, of course. Ease of publication, a fundamental strength of blogging, can also be its Achilles’ heel. Passionate, raw emotion that might feel so necessary to articulate at the moment can lead to regret, or worse [5]. Blogging about medicine and health care as a physician requires restraint and self-editing, not unlike the self-monitoring expected of physicians with respect to ethical conduct [6]. In addition, the lack of a structured, recognizable editing body can undermine the perceived quality or reliability of content published in an informal setting like a blog.

In her writing, Dr. O’Connell is utilizing a divisive feature of blogging: writing anonymously. Through more traditional publishing routes, physician writers take responsibility for their work. Blogging, by contrast, allows authors to determine how much of their true identity they wish to reveal. Medical professionalism requires a degree of accountability from physicians, and, while the protection of anonymous blogging permits frankness and candor, it also implies that the author does not want his or her real identity entangled with the stories being shared online [7]. Dr. O’Connell is using her alter ego, theGrouchyMD, to say “pretty edgy things about the hospital and the residency,” and it is unclear whether she would make similar statements were she signing her real name.

Responsible Writing and Venting

Physicians are legally and morally responsible for maintaining patient privacy [8]. Physician writers must balance their responsibility and obligations to patients with their duty to readers. When Dr. Baker confronts Dr. O’Connell, the latter defends herself by saying “I just need to vent.” What is this need, and is it so important that it subordinates the patient’s interests?

Dr. O’Connell defends her writing on the grounds that changing names and identifying information relieves her of wrongdoing. Can an individual patient be de-identified completely? The context of her storytelling provides enough evidence, narrative fingerprints, that those familiar with the events could extrapolate the real identities of the people involved. It is evident from Dr. Baker’s quick discovery of theGrouchyMD’s identity that Dr. O’Connell’s stories pose a potential threat to her patients’ privacy.

Another argument holds that what matters is not whether a patient may recognize herself, but rather that the physician took information obtained in a confidential relationship and used it for personal ends. De-identification doesn’t change the moral breach; it only reduces the physician’s risk of being caught.

The stakes are high for physician writers, who represent not only themselves but also their practice and profession. A physician’s blog is more than a personal journal in the public domain, because readers are also patients [1]. When a physician blogs about a patient encounter, that narrative weaves itself into the public perception of doctors as a whole and can directly impact patient care. Physician writers must be cognizant of their influence and mindful of the potential for harm as a result of their actions.

A negative portrayal of the patient-doctor relationship may cause readers who identify with the patients in Dr. O’Connell’s stories to question their relationships with their own doctors. When Dr. O’Connell criticizes a 53-year-old patient for seeking fertility treatments as “selfish and irresponsible,” she creates a rift between herself and older women pursuing pregnancy and possibly between those women and their doctors—they may worry that their physicians judge them in the same way. Dr. O’Connell also misses an opportunity for self-reflection when Dr. Baker approaches her. She fails to see that her criticisms of older women seeking fertility treatments—selfishness and irresponsibility—could be leveled against her and her blogging.

The accessibility of blogs puts physician writers in a position to have widespread positive impact. Bloggers who represent the best of the medical profession reflect well on everyone in a white coat. Online forums allow physicians to engage a wide audience, where they can dispel misleading or false medical information, participate in discussion of current issues in health care, and shed light on certain aspects of medicine from a physician’s perspective.

Blogs can also be a humanizing element for physicians, a way to connect with people outside the confines of the hospital. In a survey of physician bloggers, the most commonly reported reasons for blogging included sharing knowledge or skills, influencing the thinking of others, and creative expression [9]. Dr. O’Connell identifies these as motivations for her own blogging, saying, “It’s really useful for people to get sensible general advice,” and sees her physician-authored blog as a way to counteract “whatever junk is out there on the web.” Here, Dr. O’Connell is evincing professional competency, using her technical skills and knowledge for the benefit of her readers. By providing only general medical advice, she is reaching out to those in search of medical information, without venturing into the ethical gray area of online diagnoses [10].

As theGrouchyMD, Dr. O’Connell illustrates both the power and the pitfalls of physician blogging. She is sharing the truth about her experience as a doctor, but treading roughly on patient privacy. She is providing reliable medical information to a large audience, but may be alienating some patients with her cutting commentary. If we were in Dr. Baker’s shoes, what could we offer Dr. O’Connell as a touchstone for appropriate Internet use?

How to Responsibly Use the Internet

Blogging has enormous potential to enrich and strengthen patient-doctor communication if used judiciously [11]. We propose the following guidelines for physician bloggers:

• First and foremost, always employ the Golden Rule of the Internet: if you wouldn’t say it in person, don’t say it online.
• Question intent: if publishing a story will benefit only you, the author, consider keeping it to yourself. A fine line separates thought-provoking and inflammatory commentary, and a narrative that is personal is not necessarily insightful.
• Keep it clean: as a physician in the public eye, you represent not only yourself but also your profession and any affiliated institutions.
• Care for your patients on the page: you are responsible for their well-being even when they are not physically in your presence.