Wednesday, June 9, 2010

Should You Friend Your Doctor??

My friend and colleague Katherine Chretien has a provocative Op-Ed in USA Today entitled A doctor's request: Please don't 'friend' me which asks the question whether doctors and patients should interact in social networking sites such as Facebook. Social networking has huge potential in health care regarding the sharing of information and ideas, and could possibly even enhance communication between doctors and patients. However, as Dr. Chretien points out, many physicians have steered clear of social networking sites, and those who do, "actively dread having a patient add them as a friend." The main problems with social networking and patient-physician interactions boils down to confidentiality/security and boundaries.

Confidentiality/security is less murky issue to deal with, and is applicable to all online communications between doctors and patients. First, there has to be privacy. If a patient wants to post their entire medical history to the world, they have every right to do this, but doctors have to ethically and legally maintain a patient's privacy. This should not be too difficult, but could get tricky in a social networking world. If a patient posts "Not feeling well today," a reply from their physician "don't forget to take your meds," would likely be a violation of privacy and confidentiality. In addition, all online communication must be secure. Regular email does not even meet that requirement. In fact, unlike email, both parties need to be logged in to Facebook to send and receive messages, making Facebook a better choice for direct communication between doctors and patient then regular email. Part of security also means encryption. According to Facebook they "always posts to a secure page when users are logging in and employs industry standard encryption."

The bigger problem has to do with boundaries. The doctor and patient relationship is unique in that is should be close and personal, but if too close, the doctor's objectivity could be compromised. This is why it is considered unwise (and sometimes unethical) for physicians to treat their relatives. According to Dr. Chretien, "the thought of opening up our personal pages filled with family photos, off-the-cuff remarks and potentially, relationship status and political and/or religious views to our patients gives us the heebie-jeebies." However, is having family photos online any different than having family photos in one's office? Does an off the cuff remark revealing a physician's political slant any different in the office than on the web? Physicians are often known to personalize their office space with items of personal importance and significance. Family photos, an artifact from a vacation, a golfing trophy, a treasured gift from a patient, etc. I believe this is a good thing. It humanizes physicians and hopefully assists patients in making connections with us.

The two problems with Facebook are controlling one's own privacy and the use of the word "friend." Facebook was founded by Mark Zuckerberg with his college roommates and fellow computer science students. In other words, it was invented by kids. The term used to link one another is "friend." However, this is not "friend" the noun which we are all familiar with, but rather "friend" the verb. Though "friend" the verb can theoretically used to mean "befriend," in conjunction with Facebook it is the mechanism by which one connects with another individual online. The confusion is not unique to the doctor-patient relationship. I am sure many young adults wonder what to do when a parent "friends" them. If instead of "friend", Zuckerberg and colleagues had used the word "connect', we would probably be less concerned about boundary issues. Is it wrong for a physician to "connect" with patients online?

The issue of controlling one's own privacy is likely what truly concerns many physicians when considering using social networking platforms like Facebook with patients. After all, the physician who personalizes his or her office space has carefully decided what he or she wants patients to know about them. Even if a physician is careful in posting information on Facebook knowing that patient-"friends" might see, other non-patient "friends" can tag the physician in a compromising photo or leave an inappropriate reply that could be easily viewed by the patient. This is obviously a barrier, but this barrier is easily overcome. The easiest way to avoid this problem is to have two separate Facebook accounts: a professional/patient account and a private/personal account. A variant of this would be setting up a "Fan" page. (Please feel free to click on the blue box with the "F" to the right to become a "fan" of Dr. Mintz). Finally, any Facebook user should be familiar with the privacy settings on Facebook. These can be customized. For example, you might create a groups called "patients", "relatives" and "close personal friends"; assigning different permissions to each of these groups.

As the Op-Ed points out, there are currently no national guidelines for social media use by physicians and, as mentioned above, confidentiality and boundary issues are difficult and controlling one's own privacy may not be easy for many physicians. However, most of the barriers for using social networking between doctors and patients can be overcome. Given that, and the potential uses and benefits social networking can provide, I would somewhat disagree with my friend (correct usage of the noun) that physicians shouldn't be "friends" on Facebook with patients. However, if they do, they should proceed with extreme caution.


Unknown said...

I'm with you 100% on this topic, Dr. Mintz. I find the furor over Facebook, Twitter, and email ludicrous. PCPs need to keep their patients healthy, and FB and Twitter offer excellent venues for sharing the latest research on vitamins, exercise, diet, supplements, preferred screening methods, preferred treatments. Why should a patient have to spend an afternoon and a co-pay to get that when you could be seeing patients who really need a doctor's care? Thanks for the dose of sanity.

Anonymous said...


Do you know how the statistic staff are paid in a hospital since they are non-medical personnel and they can't generate revenues from medical practice for a hospital? I guess that their salary must be paid from the research funding raised by the hospitals from pharmaceutical industry. Dr.Nissen claimed that he had never received any funding directly from the industry, and all the money he received from industry went to his charity. Is there any source we can find out how much funding he received from industry that went to his charity? Or his charity is a part of cleveland clinic Foundation?

Dr. Lincoff disclosed that he received $25,000.00 from Takeda for performing the meta-analysis of 19 studies on Actos in which 80% of the data were pooled from PROactive study. PROactive study was not considered as a valid study by views of many endocrinologists in both Europe and US, because the conduct of the clinical trial was somehow violated the GCP, such as revised the secondary endpoint 12 days before the data lock, and some members on DSMB, the data safety monitoring board already knew that the study would miss the secondary endpoint, so they revised the secondary endpoint when the data already unblinded to some of the DSMB members. At this point, the validity of the meta-analysis for the 19 studies on Actos was questionale, right?

Of course, this meta-analysis was paid by the sponsor, Takeda. Is there any way that the public can find out the financial link between these two entities (Cleveland Clinic vs. Takeda)? Lincoff is a medical staff and he had to disclose his extra income received from any source beside of his salary paid by the hospital for tax purpose, but what about Nissen's charity? and who pays the salary to Kathy Wolski since she is not a medical staff? If Nissen was concerned the safety of Avandia, then the congetive heart failure should be the top safety issue for both Avandia and Actos, and that was the purpose of Boxed Warning added to the package insert on both drugs. Why he ignored this class effect of TZD, and manipulated the public safety concern from congestive heart failure to MI or cardiac death,which one is the side effect of the drug, and the other is the disease complication?

valentina said...

Hello, my name is Valentina Parada, and I´m a medicine student from Universidad Católica Del Maule, Talca, Chile.
I got here because I was looking for an interesting medical´s blog, and I think your blog talks about very exciting topics like this one.
Well I am a Facebook´s fan too, for this reason I think it´s a very good idea that physicians have their patient in their Facebook, so they can help them anytime.
I also think that there is mutual benefit, because if there is any doubt about the treatment or if the patient needs to talk about a specific topic, the doctor should solve it via online, so the patients doesn’t need to visit personally their doctors. And doctor s don’t need to spend all day in their offices resolving questions of their patients. But as you say the doctor should be very careful with his Facebook´s posts because their patients may be watching them.
Finally I wonder if have you ever had a problem with a patient by a publication in your Facebook?
Thank you very much, I hope you answer soon.

Dr. Matthew Mintz said...

thanks. haven't had a problem yet

Anne Marie Cunningham said...

I work in GP practice where we don't 'personalise' our rooms. And I wouldn't feel comfortable making off-hand remarks about my political views either. So perhaps we come to this with different ideas about the health professional= patient relationships. Sometimes I am asked about my personal like and I answer politely. But I don't feel that it is appropriate for me to project this to others. When I go to see the doctor I hope that it is 'all about me' and I hope I can be the same for patients visiting me.

Dr. Matthew Mintz said...

Anne Marie,
You make some very good points. In the US, it is very common for primary care physicians to have an office where they speak with patients and an examining room where they examine patients (though as an academic doc, my setting is a pretty sterile clinic). In the physician's office, it is not uncommon (and I would argue likely expected) that the physician, in addition to his or her diplomas and certificates, to have some personal items out.
Regardless, there is still a fine line between what you can share that might be considered too personal, and this line may very based on cultural and personal beliefs. Dr. Katherine Chretien has made the arguement that since social media, especially Facebook, has such a wealth of material that is not always easy to manage, "friending" a patient is too risky. However, I believe that sharing some personal information is not only OK, but may actually strengthen the doctor patient relationship. The caveat is that one has to be very, very careful. I have my Facebook page, which some patients are "friends" set up such that only limited information is revealed. In addition, I have set up groups in Facebook, such that most of my Facebook posts which are meant for family and friends will never be seen by my patient "friends."

Anonymous said...

Hey, I dont see why doctors would mind paitents seeing there family photos, ect. When they know almost every detail about you, on my behalf it makes me feel more comfortable to know a bit about them as well, I have not known my doctor for that long about 4 months maybe but I saw him every single day for 2 months while in hospital and I fell were kinda friends now, do all I want to know is can he accept my friend request if he wishes? Or is it some kind of law saying doctors and paitents are not to have any sort of relationship after treatment.

Anonymous said...

I'd have to agree that "friending" a doctor or patient on Social Media is too risky for both parties.

That said, in my opinion that does not mean a doctor / patient should be banned from becoming actual friends in life. In which case, there would have to be a mutual agreement to stay away from email and social media sites for both parties protection. Not sure if that's even a possibilty though? For example, I've been treated by a doctor that I feel would make a great friendship outside the office. Unfortuanltely, there are so many fears of legal liabilities that a friendship will probably never come to fruition. I dare not bring up my desire for a friendship out of respect. It's a real shame, as you cannot exactly stop yourself from connecting or bonding with someone, regardless of how you met.