To Tweet or Not to Tweet – AGA/DDW Social Media

May 8, 2011

This is a rough transcript of a brief presentation given to the American Gastroenterological Association/Digestive Disease Week.

I want to thank the AGA/Digestive Diseases Week for inviting me on this panel of speakers.  It’s exciting to see the AGA recognize the need for professional education in social media.   I’ve been on Twitter since 2008 when there were few doctors even familiar with the concept of social media.  Watching it evolve I’ve been forced to confront some of the real issues facing doctors in the social space.  Hopefully over the next 20 minutes or so I’ll impart some of my hard-earned wisdom.

I have to fully disclose that the title of this presentation (Teens who Tweet) suggested that I was just going to talk about teens.  But if we look at this data from the Pew Internet and American Life Project we see that teens don’t tweet. In fact, Twitter adoption among teens appears to be almost half of what we see with young adults.  Why is that?  Two reasons: 1) Teens see Twitter as a middle-age platform 2) and it never reached early critical mass with teens.  What do teens do socially?  Text and Facebook.  And teens are interesting because while they may be active socially, they’re less inclined to bring their diseases along with them.  So as a physician you are unlikely to be approached by a teen with health related issues.  I care for lots of teens and it has yet to happen.  And digital professionalism is independent of your patient’s age.

I want to give you a couple of examples of patient contact on social media.  2-3 months ago I was friended on Facebook by a woman in my community.  I couldn’t recall who she was so I messaged back and asked how I knew her.  She replied that we didn’t know one another.  She had read my book, Colic Solved, and had a remarkably irritable 6 week old baby who was only taking 12-14 oz/day and wanted my help. So what do I do?  Is my response subject to discovery in a court of law?  Could I receive disciplinary action from my hospital for engaging in a non-secure fashion?  Would my response be an action reportable to the Texas State Board of Medical Examiners.  Or, do I have an ethical obligation to this mother who has presented her baby to me in this way?  So what would you do?? I did what I would do in any other situation, independent of the communication medium:  I did the right thing.  I got the mom’s number, called her and arranged to see her the following morning.

So while SM hold great promise for personal branding, education, public health, this case illustrates challenges beginning to face doctors in this new mode of interaction. And just because patients will occasionally approach us in the grocery store or at a restaurant doesn’t mean we stop buying groceries.  Similarly, these social media experiences will happen and it isn’t an excuse not to engage.

Looks dangerous, huh?  Actually not really if you keep your wits about you and exercise common sense.  While there are a hundred ways we can keep ourselves safe on public social platforms, I’ve boiled it down to 4 that will help keep you out of trouble.

  1. Never discuss patient-specific issues.
  2. Never be anonymous.
  3. Remember everyone’s watching
  4. Be nice

I’m going to drill down on the first two in the next couple of slides.  The last two are important but I’m not going to expand. Just remember number three:  everyone is watching and what happens on Twitter stays on Twitter, literally.  Everything is part of your digital footprint and everyone can see it:  your boss, your patients, your soon-to-be ex-wife’s attorney.  Now while that’s at once funny and scary, you should look at all this from an opportunity perspective, not a risk perspective.

So why should we never discuss patient-specific issues?  Basically everyone’s listening.  And while the patient may offer implied consent by initiating the dialog, not all patients understand the implications of disclosing personal health information.  And even if they do understand, it isn’t something that I’m comfortable with.  Keep in mind, too, that on Facebook or Twitter are difficult if not impossible to properly document.

We need to think beyond HIPAA. Very often we measure the safety of our actions against HIPAA.  But remember that HIPAA is a legal dictate.  As physicians we always have to think of the commitment to our patients beyond what the law requires.  Just because a story may be HIPAA compliant doesn’t necessarily mean that it’s appropriate for public dialog.  For example, if I see a baby with neonatal hemochromatosis in the NICU and decide to mention on Twitter that ‘today I saw an interesting case of neonatal hemochromatosis,’ this may not disclose personal information.  Yet if the mother of that baby were to read my feed it would potentially represent a breach of our trust.

You may think to yourself, ‘I’ll just change the details of my patient encounters and write about them.‘  You can do this but you have to be extremel careful.  Last week a doctor in Rhode Island chose to share a patient encounter on Facebook after she de-identified details of the encounter.  Apparently the case wasn’t de-identified quite enough and a family member identified the scenario.  She was fined and lost her privileges.

You may think to yourself, ‘I’ll create an alternate persona.  No one will know who I am.’ But anonymity creates a false sense of security and lowers the threshold for you to say things that you might not otherwise say.  The fact that my boss, chairman, patients and mother-in-law see what I write keeps me safe.  And there’s no such thing as anonymity in 2011.  You can be tracked.

Here’s how anonymity can get you in trouble:  In the mid-2000′s there was a famed medical blogger who wrote under the name of Flea – his personality was based on the rocker from the Red Hot Chile Peppers.  He was very powerful with thousands of readers.  He wrote very edgy, provocative content.  But behind this avatar was a mild-mannered Harvard trained pediatrician.  During a medical malpractice trial in 2007 felt it would be appropriate to write about the trial and specifically the personal habits of the female plaintiff attorney.  Someone made the connection, clued in the plaintiff team and during a moment that made history he was asked ‘are you Flea?‘  The case settled immediately.  Read a very interesting interview with Robert Lindeman, the doctor behind Flea.

So what should you do when a patient contacts you?  This Tweet came through on a Saturday morning when I was at my son’s baseball game (“DrV, this is X’s Dad.  We forgot, do we give one suppository or two”).  It came from the father of a child with proctitis who I had seen with 15 other patients on a Friday. So what would you do?  Can you ignore it?  Again, what’s the right thing to do?

So here’s what I do when patients try to reach me in a public social space:

  1. Take the issue offline. I simply contact the patient by phone to discuss the issue is a more private environment.
  2. Address their problem. Understand that they have a need to be met.
  3. Educate the family.  I let them know about the personal pitfalls of public disclosure of health information.  I then tell them that I can get in trouble.  Every time this has happened families understand entirely.  And through all this understand that for many of your young patients Facebook and other real-time platforms are the way they communicate.  It’s interesting that the father who messaged me about he suppository didn’t know that his tweet was public.  He didn’t understand Twitter messaging.
  4. Open a phone note and document the encounter. I always make it clear that the dialog was initiated by the patient.

Because of this you may want to initiate a communication policy for your practice or clinic.  Given all of the available channels for social dialog you need to define how and under what circumstances each channel will be used.

I might leave you with the suggestion that we as physicians have the ethical obligation to be involved with the creation of content and dialog in the health infosphere.  And as providers we have to start looking at this from an opportunity perspective rather than risk.  We have the capacity to collectively harness the most powerful communication medium since the printing press.  We can influence ideas about health.  We can change the way we’re viewed. We can be publisher and reviewer.  It’s where the patients are and its where we should be as physicians.

The link to Colic Solved is an affiliate link.


{ 6 comments }

Andrew Creme' May 8, 2011 at 12:16 pm

Dr. Vartabedian, love the thoughts and the dialogue around social media and medicine! Our firm has drafted a white paper on practical social media applications for the healthcare practitioner. I would love to email you a copy to get your thoughts!

Anne Marie Cunningham May 8, 2011 at 7:57 pm

Great! I wish I’d been there. I especially like your use of the grocery store analogy as I’ve used it before myself. http://wishfulthinkinginmedicaleducation.blogspot.com/2010/08/my-thoughts-on-health-professionals-and.html

As always I would like greater clarity about why physicians should be in the social space. As an educator I have decided that this is a good place to be horizon scanning so that I can stay up to date with emerging issues, especially around the use of technology. But I would have a hard time trying to convince one of my colleagues, who is a full-time clinician, that there is a lot to be gained by being in these spaces.

I fully recognise that this is because as yet we still have the vestiges of a socialised medical system in the UK. Everything might change in the next few years- hence the interest from the communication team in St. George’s in monitoring discussions of their hospital online.

But unless you do have good reasons for being in this space it is a risky one. At the same time there is the potential for learning and this is something that I am very interested in helping students develop skills in whilst giving them as much support as possible.

Thanks again,
Anne Marie

Ryan Madanick, MD May 8, 2011 at 10:41 pm

Thanks for posting this, Bryan. Great advice for everyone, even if they are not actively involved in social media. Enjoy the rest of DDW.

Stéfano Gonçalves Jorge May 9, 2011 at 7:31 am

Great insights on this matter, Dr. V, as always. I would like to know if it is ok for me to translate it into portuguese and post it elsewhere (with the appropriate link to this page and crediting you, of course).

Claire McCarthy May 9, 2011 at 2:51 pm

Great post. Sensible, practical, wise. A must-read for all of us health professionals who write and use social media.

Irwin Lim May 9, 2011 at 3:04 pm

Your last comments speak to me: “We have the capacity to collectively harness the most powerful communication medium since the printing press. We can influence ideas about health. We can change the way we’re viewed.”

I wrote on your site late in 2010 about my fears about commencing a blog. Those fears have dissipated. The sentiments you express are an increasing reality for me.

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