How I Handle Medical Questions on Social Sites

August 20, 2012

I received a message from physician friend about how I handle medical questions on Facebook or Twitter.  This is a common concern for doctors and it’s often used as an excuse for avoiding a public presence.  My ideas about doctor-patient communication are evolving and may well change as technology evolves.

Here are a few thoughts.

People have always asked questions.  The social web doesn’t change human curiosity, it just gives it a new avenue. What’s different is that:

  1. It’s easier to approach experts in today’s media climate.
  2. Dialog is potentially retrievable.
  3. The always-on nature of social media creates public expectations that engaged physicians are ready and willing to be their personal advisor.

Social media has lead us to believe that health assessment may easier than it really is.  But answering questions, be it at the grocery store or on Twitter, is trickier than you think.  Questions require attention, time, focus, and some kind of relationship.  And when you give advice based on a 140 character history you put yourself at risk of doing a disservice to the person asking for advice.  They have no idea that you’re doing them a disservice.  They just want a quick answer.  It’s how you think when you’re sick and you want an answer.

So how do I handle myself specifically?

I never answer patient-specific questions.

There are two types of questions that physicians may encounter in public spaces: patient-specific and patient non-specific.  I answer patient non-specific questions without reservation.  Those involving someone’s specific health issues spell trouble.  While there isn’t much precedent in this area, you could be construed as having a relationship with the patient in question …. Um, I mean the person with the question.  Where there is a relationship there is risk.

How I approach things depends on my specific relationship with the person asking the question.

There are three categories of people that reach out to me on social media.

I.  People I don’t know.  This is easy.  I tell them that I can’t offer advice to those who are not established patients.  I offer two clear reasons: It’s a mandate of my state medical board that interactions must involve clear documentation in a medical record.  Also, my involvement isn’t covered under my institution’s malpractice policy.  I’ve never encountered someone who didn’t understand these two points. 

II. Patients.  Every once in a while an established patient will reach out to me on Twitter. Here’s how I handle it:

1) I take the dialog off line.  I usually do this by at messaging back that I’d be happy to talk to them by phone.

2) I address the problem.  They reached out for a reason and I try to address their problem.

3) I discuss why it isn’t a good idea for either of us to have our dialog in public.  This typically involves a discussion of how I can get in trouble but includes potential issues related to their disclosures.  It’s interesting that many patients I speak to don’t really understand the privacy settings of the site they used to reach me.

4) I document the encounter.  I document the conversation in a phone note making it clear that it was the patient who initiated the contact in public.

How you want to be contacted by patients should probably be part of your new patient information.  Remember that social applications like Facebook represent some of the most commonly used communication platforms and we shouldn’t blame patients for using them if they haven’t been instructed otherwise.

III.  People I loosely know.  These are the hardest to handle because often I have an easy, conversational relationship with the person but this unfortunately doesn’t extrapolate to my willingness to invest significant bandwidth (see the next paragraph) on their issue.  I can’t help but feel as though I’m letting them down.  But the bottom line is that I treat these just the same as for people I don’t know.  I simply tell them I can’t do it.

What about my own family and very close friends?  They’re different.  In cases where I think I can offer help, I’ll arrange phone time in the evening, close the door to the study and spend 45 minutes getting all the facts so that I can come close to offering some direction.   That’s how long it takes.  Good input can only come when you have good information.  I work really hard to help support the established relationship that the person has with their doctor.

While many may not see it this way, my avoidance of loose advice is ultimately an act of advocacy for those who approach me.  Remember that reliable health input involves attention, time, focus and a great relationship.  The fast flowing, real-time dialog of today’s social environment doesn’t allow for all of these elements.


{ 23 comments }

Jody Schoger August 20, 2012 at 10:55 am

Bryan,

Thank you for this thoughtful and thorough post. It came right on the heels of an article circulating on FAST COMPANY about social media “guidelines/rules.”

But health is so different than brands, as are the nuances, the relationships and how different individuals perceive information. We need to constantly define these boundaries in health and social media and you’ve prompted me to think about a post from the patient perspective – what I would/would NOT ask or expect of a physician on social media.

Thanks again for being a conversation starter:)
Jody

DrV August 20, 2012 at 11:29 am

That FC question about rules has me creating my own short list. But more later. Thank you for your thoughts, Jody.

John Lynn August 20, 2012 at 11:23 am

Very thoughtful analysis of the various situations a doctor sees. How often do you get approached on social media with clinical questions? Is it a constant thing or just the occasional question? Do you see questions more from the random person you don’t know or existing patients?

DrV August 20, 2012 at 11:30 am

I get direct questions on the order of every couple of months. I wrote a book in 2007 called Colic Solved, so I get lots of direct queries regarding screaming babies who aren’t getting better. Most questions are from random folks. I hear from established patients less often.

Emily Gibson August 20, 2012 at 11:28 am

Bryan,

This is excellent advice for the physician who is very visible on line. The problem is solved by secure electronic messaging with patients as they are much less likely to ask questions in a public forum. If you figure out how to deal with acquaintances (non-patients) asking for medical advice in person at social gatherings, the library, grocery store, and church, I’d be grateful. I always feel an obligation to respond with my full attention and compassion but I feel outside wise professional boundaries. It is a tough spot to be in.

DrV August 20, 2012 at 11:41 am

These are the hardest cases, Emily. You feel connected to the person but perhaps not enough to spend 30 minutes helping them sort it out. Generally I’m quite straight forward with the idea that i’m likely not the best person to help. I’ll listen for a bit, offer some general direction but ultimately defer. For issues related to pediatric GI problems or nutrition, I always offer local folks to come vist me in my office. In these cases I’ll work with my office to expedite an appointment.

I think being direct, honest and sincere beats trying pretend that you’re able to give them exactly what they need.

Ted Leng August 20, 2012 at 1:15 pm

So what do you think about websites/apps like HealthTap and Avvo.com?
Would you advocate answering questions with the assumption that they are for “general purposes only” and not for specific patients?

DrV August 20, 2012 at 1:20 pm

Without delving into the pro’s and con’s of any particular platform, I don’t know of anyone uncomfortable with general questions. There’s a big difference between ‘when does reflux tend to go away in a baby’ and ‘why won’t my baby’s reflux go away?’

Steve Balbo August 20, 2012 at 2:31 pm

DrV
you are extremely professional. thank you for this post

DrV August 20, 2012 at 2:43 pm

Whoa…now there’s a vote of confidence. Thank you.

Kevin Darst August 20, 2012 at 3:42 pm

You seem to be talking more about direct communication, but what’s your thought on chat/twitter chat, etc, where public is invited to ask questions about a topic (concussions, flu, etc)? Are you an advocate of that format?

DrV August 20, 2012 at 4:19 pm

I believe that we have an obligation to engage on this level – and this includes answering health questions. It’s interesting that pediatricians for years have been serving as columnists in the major parenting magazines fielding questions from parents. No one ever raised concerns about it. Now we have a new medium and, suddenly, everyone runs for cover.

Interesting phenomenon.

Marjorie Shanks August 22, 2012 at 12:56 pm

You bring up an interesting point here about columnists for magazines and other media outlets. Attorneys frequently engage in these “ask the professional” type sessions as well. I would imagine they face some similar dilemmas concerning professional relationships.
I think some medical practitioners, particularly those who were not raised in the age of the internet and new media, fear social media and the convergence of patients with questions and the internet. Some fear this to the extent that they have no presence on the internet whatsoever, even as it limits access to finding their private practice online for something as simple as directions, office hours etc.

Good post. Thanks for writing on one of my favorite topics–the intersection of medicine and convergence media!

Christopher Nitkin August 20, 2012 at 3:48 pm

First, DrV, thank you for writing such a wonderful blog – I hope to have such a well-regarded online presence someday!

As a pediatric resident and newcomer to social media, I don’t have to address this issue regularly, but I appreciate your thoughtfulness. Watching how this evolves over the next couple of years will surely help when it *does* become a factor for me. As for right now, only half-jokingly do I advise friends and family to talk with their own doctor with their concerns, in part because I’m in training, but mostly so that their PCP remains in the loop!

And @Emily, for what it’s worth, I also feel uncomfortable with acquaintances and advice… even more so when they seem dissatisfied with the care they receive and ask me what *I* would have done. Although I have a vague idea of what the “standard of care” is on some topics, I don’t know the details they’ve discussed with their physician, what he/she was thinking at that time, and what the follow-up plan is.

If it seems reasonable, I sometimes suggest that my acquaintance bring up a specific diagnosis or specialist when they visit their PCP – if she has chronic hand pains & a strong family history of rheumatoid arthritis, I might mention that and suggest asking about the possibility of seeing a rheumatologist… do you think this is overstepping my bounds, or do you take a similar approach with non-patients?

DrV August 20, 2012 at 4:21 pm

For me this would be part of a conversation I would have with someone I knew pretty well and had spent some time with discussing the matter. But no, I don’t think this is overstepping so long as you do your best to support the persons treating doc. IMHO.

Mike Thompson August 21, 2012 at 6:43 am

Bryan -
As usual great, well articulated advice.
Mike

Amy Rettig August 21, 2012 at 7:06 am

The thing that strikes me most about your blog post is not so much about social media but about the time it takes to offer good direction. “…spend 45 minutes getting all the facts so that I can come close to offering some direction. That’s how long it takes. Good input can only come when you have good information.” Perhaps you are only referring to a family situation, but I have to wonder… With the “5 minute physician visit” is that enough time to have a healthcare relationship with a patient? Is that much different than an encounter on Facebook? Thanks for the post!

Greg Smith MD August 21, 2012 at 7:15 pm

Bryan,

Good job.
As previously discussed, our state and the Department of Mental Health in particular are now struggling with what is appropriate in this arena, including social media contacts, email, and other online interfaces.
Of course, the opinion of accreditation bodies like CARF, who will be visiting our center next month, also start to come into play.
This is an evolving area in medicine that is surely in for some growing pains in the next few years.

Greg

DrV August 21, 2012 at 9:25 pm

I always put psychiatrists in a different box when it comes to their public presence and the way they relate to patients. I’d love to discuss this sometime. Needs clarification and leadership.

Gregg Masters (@2healthguru) August 23, 2012 at 12:27 pm

Bryan:

In the ‘it takes a village’ mantra, you continue to serve as one of it’s key stewards. Your willingness to internally reflect and share insights on the blog is both ‘walking the talk’, and defining the possibilities from the medium.

Thanks for your continued engagement, and the light you provide.

Some thoughts from the ‘people I loosely know’ domain.

Benoit Bisson August 26, 2012 at 8:53 am

Thank you for this very well balanced and enlightening post. As a patient living in Canada and working in some advocacy groups with other cancer patients, I often have to talk with patients about access to their doctors. While the topics of email and SMS comes up fairly often, so do social media and your post gives a very clear and understandable description of proper use. Rather than the “I don’t deal with patients on social media” or “I couldn’t be bothered with using things like Facebook or Twitter”, which can so easily be perceived as a brush off, you demonstrate simply and clearly the limitations, all the while caring both for the patient and all the legal and ethical implications. Thank you for such clarity. I expect to frequently share the link to this post and, if you do not mind, translate some excerpts from it for groups of mostly French-speaking patients.

Greg Smith MD August 26, 2012 at 9:19 am

Benoit,

Very well said.
That’s the crux of it to me. We all need to figure out how to be compassionate physicians, responsive to patients, and engaged in real time using these widely available tools, while still maintaining time-honored principles of confidentiality and respect.
I for one LOVE to be connected and available both to colleagues and patents. It’s just a matter of figuring out how to best do this moving forward.
Enjoyed your comment.

Greg

Marjorie Shanks August 27, 2012 at 9:27 am

Dr. V.,
Your well-written post here made me recall a situation a few years ago when a patient of mine (as a lactation consultant) stopped me at a football game to look at her breast.
Yes, you read that correctly.
I wrote a post about on my blog and cited you.
http://www.pawannabe.com/2012/08/what-to-do-when-client-wants-to-show.html

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