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Blogging Guidelines For Physicians

There’s been quite a kerfuffle over the “Unprofessional” post Dr V wrote. A lot of people have been very shrill in denouncing physicians who write about their experiences using social media — blogs, twitter, facebook, etc — with particular emphasis on those who do not use their real names.

So, while I won’t tell someone how they should blog/tweet, or try to impose my vision of professional standards on a community that clearly is still coming to consensus with public conversations by healthcare workers, I will offer you my personal guidelines and values that I use in determining what I am willing to put into the public domain. These are just my opinions; your mileage may vary.

As a general principle: patients give physicians and nurses access to intimate details of their lives and they have a reasonable and valid expectations that we will respect their privacy and dignity. When using social media, that does need to be maintained. How you do that requires careful attention and may be controversial regardless of your approach.

Don’t blog or tweet anything that you wouldn’t want you boss/hospital administration to read. Stress test yourself by informing your employer or CEO about your blog and invite them to read it. That will keep you honest!

HIPPA — it’s the law, and it’s a minimum standard for how much de-identified information you can publicly share. I would argue that how far you need to go beyond HIPPA depends on what you are writing, and the tone. If it’s a straight-up medical science, such as an educational case report, I would contend that fairly little beyond the minimum information needs to be removed. If the case is unique, intimate or newsworthy, you may need to go a bit further.

Even though you may not have your name on your blog or twitter, do not think for a moment that you are anonymous. It would take creative hackers about ten minutes to figure out your real name and location (ask me how I know!). A lawyer would also be able to get that info easily. Don’t put it out there unless you would be willing to stand by it with your real name there. That said, I think there are good reasons to maintain some degree of anonymity. Every patient I see in the ER gets my card, and I suspect that more than one has gone home and googled me. If one were to find this blog, he or she might be quite upset at the mere prospect that their privacy might be violated. Even the possibility of that I find unacceptable, so I keep my name off the blog. Yes, it’s easy enough to find out who I am. But I think it’s important to try to protect patients from even the fear that their privacy will be violated.

Which brings me to the next and maybe most important point: don’t blog about real patients. This is tricky. When you have a blog (or live on twitter) and you see something noteworthy in the course of your professional life, the reflex is to share it, especially when the audience is a mostly professional one. It feels like you’re chatting at the nursing station, but it’s more like the hospital elevator or lobby — a public place. So look carefully at the case, figure out what about it that is worth sharing, and distill it down to that. Then rebuild the case with completely bogus details. Your authenticity is what makes your stories interesting and valuable, so it’s challenging to create a realistic fiction which conveys the central pont in a believable manner. I’m sorry to say this, but all of the stories I have ever told on this blog, at least since the very early days, have been made up out of whole cloth. Each story did illustrate a real point that arose out of a real case. But I generalize, fictionalize, and use archetypes to illustrate the concept. I’ve seen enough patients to be able to build a credible composite. Also, don’t do it in real time. Write up a case and let it marinate for a while. The more unique the case, the more obfuscation and time are needed to ensure that your post is not traceable to the incident patient.

When you do write about an appropriately de-identified and fictionalized patient encounter, add some redeeming value. If the central point of your post is “people suck” or “Patients are stupid and I hate them,” then just possibly you need to reconsider before you hit publish. As i said above, education is an excellent value-added element for a medical post. Some bloggers write beautiful stories about the human condition, uplifting and sad alike. But there are other stories to tell, about your life on the other side of the gurney, and those are good, too. Sometimes a patient makes you angry or afraid, and those are valid stories to tell. Avoid telling patient stories for their simple prurient interest. If the central point of your story is “can you believe this?” find a better point before you put it out there, or delete it.

Don’t eschew humor. People are weird and wonderful and the things they do are hysterical. There’s nothing wrong with acknowleding that fact. Many patients, in real life, will laugh at themselves. But don’t laugh *at* patients; that is belittling and demeaning. Find the humor and celebrate it. Be positive and affirming. Be self-deprecating. Humor and respect are not incompatible, but it is oh-so-easy to cross the line to the “bad” humor.

This is something new, and it’s going to take time for the world to adapt to it. In the old days (defined as prior to 2003) medical conversations were limited to private discussions in the doctors’ lounge and the occasional book. Now they take place in the public sphere. I think that’s a net positive. It’s good for doctors and nurses to be able to easily express their emotions and their experiences. It’s also good for patients to be able to see behind the veil of what really goes on in the health care arena. Is it perhaps disconcerting? Yes. Is it easy for frustrated or burnt-out docs to overstep the bounds of propriety? Sure. it is not, however, the medium which is the problem. It is what you say that counts, and how you say it.

I should also add, as a point of order, that if you go back through the nearly two thousand posts published here over the last six years, you will probably find some which do not live up to these principles. I have certainly learned, matured and evolved as a blogger in this time. In the spirit of intellectual honesty, I don’t generally retro-edit or delete posts which turned out poorly. So feel free to play gotcha; it’s easy. And I’ll plead guilty in advance.

I hope these guidelines are useful to you, if only to understand where I am coming from. I’m a little disturbed by the prospect of a bunch of busybodies trying to regulate what physicians can share online, so my intent here is to show that an anonymous blogger can approach the task from a principled and positive perspective. Feel free to let me know in the comments how I can do better.

*This blog post was originally published at Movin' Meat*


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One Response to “Blogging Guidelines For Physicians”

  1. Simon Sikorski, M.D. Twitter @medmarketingcoe says:

    Over 9 years in healthcare marketing there is one issue that needs to be adddressed: that the education on what is online presence and social media is not available.

    At a time when almost every resident or fellow is discouraged from having an online presence by their peers and the only news we ever hear about is doctors getting in trouble because of social media, we’re not going to get much traction.

    We need to start educating our doctors in medical school and encourage communications with patients throughout their careers.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

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Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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