I recently got into a discussion with a couple friends about doctors and blogging.  Why don’t we more doctors out there?  Of the hundreds of thousands of doctors I’d expect more taking a voice.  Even during the U.S. health care reform debate.  Crickets.

Of course there are doctors who blog, but the numbers are slim.  What’s behind it?

Passion.  Pushing great content requires a passionate interest in changing ideas and making a difference.  There’s malaise in medicine right now.  Margins are slim.  Physicians are losing control of what’s happening around them. The fire in the belly that drove so many doctors to choose medicine has given way to a preoccupation with survival.

Late adopters.  Most doctors think a blog is something that deviant teens do on a cell phone.  There’s endemic ignorance in the medical community surrounding social technology.  Can we teach ‘em?  Maybe.  But I think this is a generational issue that will work itself out with time.  The use of social technology to facilitate dialog between doctor and patient will evolve over the next several years as 1) technology evolves and 2) digital communication becomes a standard.  Keep in mind that many of us still work with doctors who grew up using rotary phones.

They don’t need the business. Sure there are the tummy tuckers and the lapband docs who are lobbying for customers.  But for most primary care doctors, the market is such that more patients doesn’t necessarily add up to a healthier bottom line.

They don’t have a business.  Physician practices are folding faster than beach chairs at high tide.  Consolidation of medical business will mean that personal and practice branding will take a back seat to hospital and clinic marketing.  If it hasn’t happened already, your small town solo practice doctor will be working 9-5 under a hospital or large managed group.

Blogs are so…2000. Communication is moving closer to real time.  The revolution that started as Moveable Type has given way to new platforms.  Blog entries are becoming shorter and lifestreaming applications like Posterous gaining ground.  I see more physicians finding their voice in the fast moving streams of Twitter and Facebook.  Maybe these better suit the mindset and lifestyle of today’s doctor.

As the medical profession is redefined and resurrected expect excited, passionate voices to emerge.  I’m just not sure that the weblog will be where those voices will live.

They say transparency’s king. The more you share the better you look. But I’ve got rules. Here are a few things you won’t find in my Twitter stream:

Beer. I was recently speaking at a meeting out of town and caught up with some friends at the end of the day to visit and have a beer. I was in a different time zone and noted on Twitter the specific microbrew I was enjoying. The following week in my clinic a parent commented on my social activity. While I’m no stranger to transparency, the realization of my visibility was eye-opening. It reminded me that everyone’s watching and 140 characters doesn’t offer enough space to explain the why, or the time zone, of what I’m doing. So I’ve sworn to keep activities like beer consumption out of my twitter stream.

My kids. I try to keep my children out of my social footprint as much as possible. But as most of you who follow me know, they sneak their cute little selves in on occasion. It’s unfortunate because everybody loves hearing about my kids. This is at the request of my wife who’s a booger about privacy. I do mention the occasional date night with my daughter but, by and large, you won’t hear much. Kids are great jumping off points for personal digression but we have to be careful about using them to our own advantage.

Patients. With the exception of broad examples or aggressively deidentified stories I try to keep patients out of my social dialog. They creep in occasionally because they’re such a huge part of my world but typically I catch myself.
Their circumstances are their property and to use that without their expressed permission is a violation of their trust – even if HIPAA compliant.

Work grievances. Sure I’ve got problems in my clinic just like every other doctor in the free world. And I love to vent on occasion but I try to keep it off-line. My community’s got nothing to gain from it and no one likes a negative Nelly (or Nelson in my case).

Bad language. Don’t tweet anything you wouldn’t say in front of the Virgin Mary. Again, everyone’s listening. In a tweet this morning from Mike Cadogan, Emergency physician in Perth and author at Life in the Fast Lane, he makes it a rule to avoid “sex, swearing and relationship issues”. Solid advice.

Consumer complaints. I always think it’s in poor taste when a prominent member of the SoMe community broadcasts an isolated negative consumer experience in order to make a company jump (“I’ve got followers. Do as I say or the brand gets it”). In a way it represents journalistic irresponsibility. Your negative experience at the boarding gate isn’t my business and leveraging a large personal network to try to get quick results is a cheap tactic.

I’ll add more as they come to mind.  What do you avoid in your social world?

The time is approaching when businesses will want to capture the eyes and minds of physicians in the social world. Throwaways and mailouts will give way to more current channels of communication. Friends in the health industry ask how they should connect with physicians using social media channels.

The rules really aren’t much different but here are a couple of things the consultants will never tell you:

I’m not on Sermo. While Sermo and Ozmosis may seem like obvious targets, physician specific verticals are tricky. The road to the successful physician network is littered with the skeletons of startups who went broke trying to capture our eyeballs. While its hard to ignore Forrester’s bullish analysis of services like Sermo, I don’t expect the enthusiasm to be sustained. Look to the next iteration of IMedExchange to possibly be a game changer in this area. Until then, the connectors who are going to get you where you want to go aren’t necessarily hangin’
with other doctors. They’re found in the wild.

We’re not talkin’ about pills. If you listen to physicians on social platforms you may be surprised to learn that we’re not always talking about medicine. Sure we chime in on healthcare reform and some are in it only to pimp their health sites and blogs, but the real conversations fall off center of traditional medical things. While it’s  possible that the next generation of physicians will to use social networks primarily for the dissemination of professional information, I suspect that the way to a physician’s heart and mind is through the everyday dialog.

Remember the Law of the Few. In The Tipping Point (and long before Twitter) Malcolm Gladwell wrote about The Law of the Few which suggests that “the success of any kind of social epidemic is heavily dependent upon the involvement of a few people with a particularly rare set of social gifts.” These few are referred to
as Connectors – those with a special gift for bringing the world together. Look for physician connectors. Listen to them and watch what they do. Most organizations fail to make the meaningful connections with the real medical influencers that bear fruit on the major social platforms.

Look at Scott Monty. The health industry doesn’t have to reinvent the wheel when it comes to connecting with someone like me. I have always asked: “Where’s the Scott Monty of healthcare?” When will United Healthcare or Pfizer replicate the success of Ford? It isn’t complicated. Watch Scott on Twitter. See how he connects. Get a sense of how he makes people feel. Watch where he speaks. And who ever heard of an automobile company appearing at SXSW to offer free rides? He had apparently.

A few healthcare socialites who are making great headway: Marc Monseau (Johnson & Johnson), Greg Matthews (Humana), and Lee Aase (Mayo Clinic).

“90% of social is just showing up.” I took a lot of heat when I posted this quote on Twitter a few months back. But I think there’s something to it. Everyone wants to believe that social success comes from deep, ‘meaningful’ relationships. These descriptors are relative in the virtual world. Social media isn’t rocket science and simple visibility has real value when you’re starting out. Find socially active doctors. Be present. Be real. See how things evolve.

We’re not there yet. Be wary of industry-driven surveys fashioned to make you believe the medical world is spending all its time on Twitter or physician specific networks. The numbers of physicians meaningfully engaged isn’t substantial at this point. That’s because we’re busy. Windows of online opportunity with physicians are narrow. Despite the digital idealism of Health 2.0, the art of medicine still involves one individual touching another.  And it’s hard to do that on Facebook.

As the next generation of wired physicians grow into positions of power, expect real online engagement to evolve as a meaningful avenue for interaction. Until then, scrappy, smart, creative strategy that genuinely understands and respects the behavior of the social physician will rule the space.

Last week someone posted on Twitter that they had swallowed a plastic toothpick. What to do? So they turned to the hive for help.

“What should I do?” I thought as I read my Twitter feed. I was paralyzed in a way. I wanted to share my experience with hundreds of patients had swallowed pins, toothpicks and other pointy things. I specialize in just this sort of thing.

But short of a random comment about gastric emptying, I kept to myself.

Why? Because once I lend a hand I’m all in. The simple offer of patient-specific advice constitutes a relationship in the eyes of the law. Once involved, I potentially share responsibility in whatever happens to someone. Crazy but true. It’s just a matter of time before slip-and-fall lawyers hold physicians accountable for helping out in the social sphere.

Doctors aren’t the only ones wearing targets.

In the virtual land grab to get a piece of the chronically ill we’ve witnessed the growth of a cottage industry composed of alternative providers. I suspect that well-insured health sites providing safe harbor for mavens, disease experts, gurus, advisors and other self-anointed authorities will at some point feel the sting of the trial bar.

Attorneys and gurus aside, health professionals need to worry about doing the very best for those looking for help.

Here’s a thought: Unless a practitioner has the critical details of someone’s current complaint, a complete history, record of medications/allergies, a medium by which crystal-clear communication can be exchanged and a reproducible record where it can all be recorded, it’s risky and potentially irresponsible to offer passing medical advice.

That’s the kind of advocacy you won’t hear much about.

The heady exuberance of open source medical advice will play itself out. The market’s never wrong. Good, responsible care, however, will never go out of style.

And one last thing: What if you know I read about the toothpick and failed to lend a hand? Let’s not go there…

Recently I wrote about how to handle things when patients try to engage doctors in the social media space. If you missed it you can read it here. If you want to save yourself 5 minutes consider the bottom line: Doctors and patients shouldn’t be discussing patient-specific issues in the social space.

I heard from Ted Eytan regarding my post:

The question is interesting: If the patient initiates the dialog is open discussion of a specific medical problem then okay?

I wish it were that simple.

It’s important to discriminate between what patients do on their own and what patients and physicians do together. Patients (lets call them people, shall we?) can effectively do as they please. You can live tweet your vasectomy or post your pathology report on your blog. Transparency is, after all, a badge of honor.

But when patients (I mean people) and doctors get together it gets a little trickier.

Here’s why:

If it’s okay with you is it okay with me? Open discussion of privileged medical information requires written consent. Healthcare attorneys have suggested that the initiation of communication by the patient implies consent. But don’t look for me to be the guinea pig when this one’s tested in the courts. Bottom line: permission to discuss is a little more complicated than you might think.

Documentation.  Physicians bear the responsibility of documenting everything that happens between doctor and patient. From state medical boards to third party payers, physicians are obligated to get it all down.

More importantly, the documentation on most social platforms isn’t detailed enough for other medical professionals or auditors to follow what’s gone on between you and your caregiver. Let’s not forget that Twitter has a habit of disappearing after a couple of weeks.

What are you really saying? Then there’s the issue of assessing a febrile infant in under 140 characters. If you’ve ever cared for the sick you know that sorting out problems isn’t always easy. Assessment of even the simplest medical issue requires clear responses to clearly understood questions. Current technology isn’t built for this kind of exchange (HelloHealth not included).

It just isn’t smart.  Sharing detailed personal health information in a public forum isn’t smart. Sure the tongue-in-cheek comment about your ingrown toenail isn’t likely to create problems. Discussions about anything more serious isn’t for others to hear. Keep in mind that everyone from employers to insurance companies are tuning in to what you have to say.

So do we shutter the idea of any interaction between doctors and patients? Absolutely not. E-patients and physicians need to be together socially. This only helps our relationship. This is where the real power of social health lies.

There are plenty of very accessible and private formats by which you can communicate with your doctor. And if your doctor isn’t available by those means it’s really unlikely you’ll find her rootin’ around on Twitter.

I had lunch with a physician colleague recently. In the course of our discussion Twitter came up and I tried to explain its potential benefits. But despite my spot-on analogies he just didn’t understand why this would be of value to him.

Then I realized it may very well have no value for him.

As a middle-aged divorcee with college-aged children and a stable practice he freely admits that he doesn’t yearn for much. Investment into his career isn’t a priority. He has few aspirations beyond digital photography which he prefers to do alone. He’s actually very happy just as he is.

So what’s value proposition for Facebook with someone like this? What’s the return on involvement with Twitter? I’m not sure there is one.

There are those who recognize the value of relationships and there are those who don’t. There are those who recognize the value of relationships but find them less important. While the benefits of social media are obvious to those who reap the benefits, there are those who have no aspirations beyond what’s in their immediate environment.

And technology will never change that.

Online socialization is growing. Information is flowing faster than ever and the fastest flowing stuff relates to health. As the dissemination of health information via social platforms escalates, should physicians look more seriously at weighing in? Perhaps more importantly, do physicians have an ethical obligation to participate in health-related dialog?

Sounds crazy, I know. After all, physicians have always viewed the Internet as a place that nosy, hypochondriacs go to snoop around. “Go online at your own risk and be careful of chatrooms,” patients are told. Then they’re left alone at the edge of cyberspace.

Perhaps its time to change the mindset

I believe physicians and their organizations have an obligation to participate in online dialog. Sound reason, good clinical judgment, and evidence-based thinking need to be part of the information stream.

And doctors could change the way the world thinks if they would only get together. 60,000 is a number I reference when discussing physicians and social media. There are 60,000 members of the American Academy of Pediatrics. Every pediatrician fights vaccine misinformation, especially as they relate to autism. Consider the fact that the first two pages of a Google search for vaccines and autism are polluted with anti-vaccine propaganda driven by a loud, socially-savvy minority. If every AAP member wrote a myth-dispelling post concerning immunization just once a year, Google would be ruled by reason.

So what do physicians need to do?

Three steps for organized physician entrée into the social space:

1. Presence. Physicians need to be present. Until physicians adopt some of the basic tools of online socialization this will never happen. To be present, organizations like the AMA, ACP and AAP need to create tracks at national meetings to educate physicians on the power and critical importance of social media.
2. Organization. Unless we’re following one another or are connected under communities or networks our presence is irrelevant. While it’s been said that organizing doctors is like herding cats, social media breaks some of the traditional barriers to organization. It’s doable. It’s a way physicians can influence health behavior on a macro level.
3. Motivation. Physicians need to be motivated to change health behavior, attitudes and beliefs. Even if we’re online and organized, without a passionate and persistent interest in setting story straight the message will never be heard.

Doctors need online socialization

Physicians may need social media more than patients do. In fact, social activity may be necessary to our professional survival. With the steady march towards participatory medicine physicians are slowly becoming marginalized. Complete disconnection from the conversation doesn’t help. It’s time for physicians to see themselves as the invested other half in participatory medicine.

The role of the physician in the 21^st century will be defined by its role in the social health space. As they say in Washington DC, if you don’t show up at the table you’re likely to wind up on the menu. And so far zealots peddling misinformation are eatin’ us for lunch.

It would appear that doctors and nurses in the social space have finally arrived. This week marked the first Blog World Expo with a track dedicated to the medical blogger. BWE brought together some of the web’s most visible medical minds including Kevin Pho (KevinMD), Rob Lamberts (Musings of a Distractible Mind), Kim McAllister (Emergiblog), Bob Coffield (Health Care Law Blog), Paul Levy (Running a Hospital) Mike Sevilla (Doctor Anonymous), and Nick Genes (Blogborygmi), and many more.

From health privacy to the ethical obligation of doctors to be visible on Twitter, the panel-based dialog at Blog World Expo raised as many questions as answers. Medical professionals in the online space face remarkable challenges, especially with regard to transparency, personal boundaries, and the definition of patient privacy. It’s clear that our technology is ahead of our legal and ethical dialog.

Despite those challenges, doctors and nurses in the social space have a remarkable opportunity to build on what’s been done. Many of those at the Blog World Expo medical track have created the digital inroads that are changing the way the world sees doctors and nurses.

Among other things, the experience at Blog World Expo proved to me that online socialization will never replace the power of just getting together. It’s amazing to meet people you have watched for so long. And when you’ve sat and visited, a writer’s online voice seems to make more sense.

Thanks to Johnson & Johnson for sponsoring our track. And an even bigger thanks to Dr. Val Jones (Better Health) for pulling it all together and giving medical bloggers a voice at one of the world’s largest social media meetings.

Hopefully the role of medical professionals at Blog World Expo will continue to grow. Here are a few things I’d like to see in meetings to come:

• Think outside the blog. While he had a lot of discussion about blogs, they’re slowly evolving as a secondary notion in the social media space. The online world now runs in real time. We need to explore the role of live socialization in medicine.
• Bring in the smart people. We need to import the wisdom of non-medical social gurus to help our messaging on health. I would love to hear Steve Rubel tell me now lifestreaming could be applied in some creative way as a physician. We could all take some lessons from Chris Brogan on ways to cultivate our networks.
• Expand the role of social patient. Ultimately they are why we’re here. I expect we could all learn a lot from their involvement in the dialog.

Perhaps there are other things social health professionals need to be talking about. Let me know what you think.

It happened again last week. A patient contacted me via Twitter with a clinical question about her child. As always, I never engage patients in the social media space. When they try to initiate an online encounter I track ‘em down immediately to let them know the safe of social media and our relationship.

Here are a few things I think about when discussing the matter with patients (or parents):

1. Take the discussion offline. All dialog concerning attempts at online contact are done by phone or in person.

2. Understand they’re just looking for help. Keep in mind that when patients try to reach you via Facebook they’re just looking for help. Twitter and Facebook are now becoming standard means of interaction so why would it be so strange to contact your doctor? In my dialog with patients who have crossed the line I try to approach the issue in a way that respects where they’re coming from.

3. Give them the facts. While I’m not a lawyer, I do my very best to discuss the importance of online health privacy. Social media is for casual conversation, not privileged health information. While we will likely see the proliferation of secure social media platforms for doctor-patient communication in the future, we’re not there yet.

4. Remind them you’ll get in trouble. When I remind parents that they’re going to get me in trouble they feel bad. I don’t want to make anyone feel bad but they have to understand the potential gravity of the situation when it comes to the law, state licensing bodies and hospital privacy.

5. Point out why social media represents a risky means of communication. After detailing how I could find myself in hot water, I then try to illustrate how social media isn’t built for patient care. Among other things it’s not easy to follow what happens between a practitioner and patient on a social application. Who said what or, more importantly, was the intended plan even understood by the patient? And how do you and other members of the healthcare team refer to a plan of care? Very high tech but very sloppy.

6. Document everything. Any attempt by my patients to discuss clinical matters via Twitter or other platforms is immediately documented in the patient’s medical record. I also document that I have discussed with the patient or family the appropriate ways to contact me.

7. Make a social media policy of your own. One way to keep your patients from reaching out to your online is by creating an office social media policy of your own. Rules of engagement via social media should be just as important as on call or billing procedures. Along those lines I occasionally post friendly online reminders that public discussion of care with health professionals isn’t appropriate. I keep a few clipped screen shots of thes  posts in the event that my social medial judgment is ever called into question.

8. Block repeat offenders. Patients who don’t understand the importance of health privacy represent a risk to themselves and a major liability to you. Offer one warning and block after that.

As physicians we have the responsibility to help patients understand what isn’t always obvious. And teaching the pitfalls of online health dialog fit with that responsibility.

Recently on Twitter I unfollowed a friend who had become too noisy. Long strings of banal tweets were interfering with those in my stream who had something to say. I launched a tweet reflecting my decision but didn’t disclose the perpetrator. I then received a handful of direct messages reflecting anxious concern (“I hope it wasn’t me”).

Interesting, but not surprising.

So why do we get so upset when people stop following us? Or why do we fear losing followers? And why do some grow so painfully obsessed with their blog traffic? Perhaps we just want to be loved. Vanity is, of course, the social web’s most potent fuel.

To some extent my view of social media is unforgiving and increasingly driven by what I need. I work to follow people who offer value. I use Twitter and other feed as human filters that work for me on a variety of levels. But my interests and personal direction change from time to time. That, of course, involves regular adjustment of the filter. And adjustments involve unfollowing.

Conversely, I can’t predict the needs of my followers. I suspect that my stream’s balance of awkward insight and occasional dry humor distributed in evenhanded way has relevance to someone. But I accept that I can’t please all the people all of the time.

Now follow me out on this limb.

If social media is as much about transparency and altruistic benevolence as we’ve been lead to believe, we should be thrilled when we’re unfollowed. We have, after all, helped someone refine their human filter and get closer to where they need to go.

I suspect this idea won’t achieve widespread adoption. 

Engagement in the social media space requires a real appraisal of what we want and why we’re here. And if it’s all about needing love and someone to follow you, I might suggest a lapdog.

You can unfollow me here.