Dr. Luo is associate clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles; past president of the American Association for Technology in Psychiatry (AATP) in New York City; and Gores Informatics Advocacy chair at the AATP.

Disclosure: Dr. Luo reports no affiliation with or financial interest in any organization that may pose a conflict of interest.


 

With the increasing use of the Internet by patients and providers alike, it is not unexpected that their online lives would someday intersect. Before the days of Internet search engines, patients knew little about their providers until the day they meet. Now, patients can check the medical board for background checks on past complaints; physician rating sites from other patients; PubMed.gov to find their articles; and physician profiles on either academic, private practice, or marketing Web sites. Likewise, for physicians and other healthcare providers, the only preview of the patient was what they indicated on their first call to determine if they can come in for an intake appointment; however, nowadays many patients have a personal Web site, blog, and/or social networking accounts on services such as Facebook and MySpace. It is all too easy with the power and sophistication of today’s search engines to uncover more information about one another, be it pictures posted on Flickr, videos on YouTube, or comments posted on various blogs, discussion forums, or fan sites. Anonymity, privacy, and boundaries are at risk in cyberspace, yet the Internet also offers the power of information, decreasing isolation, and establishing helpful relationships that did not exist prior to its existence. This column explores the issues that impact the patient-physician relationship brought to bear today by social networking and other sites online.

Background

The Pew Internet & American Life Project published a survey in June 2009 entitled “The Social Life of Health Information,”1 which demonstrated that the use of the Internet for access to health information by adults in the United States has jumped from 25% in 2000 up to 61% in 2009. Specifically, 41% of those adults surveyed actually have read another person’s commentary or experience about health or medical issues from an online group, Web site, or blog. Twenty-four percent of those adults have also consulted rankings or reviews online of doctors and other healthcare providers. Similarly, 24% of adults have also consulted rankings or online reviews of hospitals and other healthcare facilities. These results reflect an increasing trend of utilizing the Internet for information in general as well as the specific use for various types of healthcare information.

Patients are increasingly sharing their health experiences with not only friends and family, but complete strangers online, as they post their experiences on blogs and medical question and support sites such as MedHelp.org2 and DailyStrength.org.3 Such postings are part of the increasing social networking healthcare phenomenon on the Internet, often referred to as Health 2.0, a reference to the Web 2.0 concept discussed in an earlier column.4 Internet posts are no longer just opinions on merchandise such as books and compact discs, but people are now revealing their intimate feelings and expressing their thoughts of suicide. Sadly, a Florida college student even committed suicide online via overdose while on a web cam.5 Social networking sites have also been in the center of controversy with the suicide death of a 13-year-old Missouri teenager, who was led to believe that she was rejected by a fictional boy on an account created by her neighbor’s mother.6 A new controversy has been the recent CNN report7 on the use of social networking site Facebook where patients are “friends” with their physicians for communication.

Issues

In the CNN article,7 the patient states that communicating with his physician via Facebook is easier and more efficient than continuing to repeatedly call the office. Facebook provides a channel for users to see if their friends are online concurrently, which provides an opportunity for a quick instant text-based chat. In addition, there is a private message feature, which then sends an e-mail alert to the user that there is a Facebook message waiting. In many ways, these communication channels are no different than e-mail and instant messaging; however, Facebook goes further in that it brings together many elements of related activities including photo and video sharing, blog-like posts with opportunity for comments by friends, creating and joining networks, and more importantly, the ability to expand on a network with suggested friends and the ability to search the network of your connections. Although patients in the CNN article7 report that watching videos of their doctor’s toddlers dancing gave them a personal connection akin to a bedside manner in cyberspace, in mental health, those levels of intimacy have different ramifications.

For psychotherapy, one of the reasons to avoid self-disclosure to patients is to minimize interference with transference, which may be an essential component of the therapeutic process. If patients connected to psychotherapists on a social networking site are able to see pictures, videos, comments, and browse through the different relationships of their therapist, the transference process will be more challenging if not impossible. Furthermore, privacy in the therapist-patient relationship will certainly be at risk as the friends of the therapist may wonder about the relationship of this new connection. Facebook does provide granular privacy settings where photos, profile information, or personal information can be shared with only friends, certain networks, or specified individuals; however, to sit down and edit each element’s privacy setting can be arduous, which heightens the risk that they will not be adjusted properly. In a research study8 of Facebook accounts of medical students and residents at the University of Florida, it was found that in >80% of the Facebook accounts analyzed, users listed personally identifiable information, and only 33% of these accounts were made private. In addition, if therapists use online social sites and browse among their patient contacts, they may become privy to information not intended for them such as use of tobacco which was denied previously or compromising photographs.9 This level of intimacy created via social network sites also transgresses boundaries in the physician-patient therapeutic relationship by changing the frame of the relationship.10 Although younger physicians and medical students may have less concern about these issues and have merged their personal and professional lives by “friending” their patients on social networks, they do recognize that they are crossing traditional professional boundaries.11

Although it is an increasing occurrence for healthcare providers to “Google” their patients, they must consider their motivation to determine whether it is an ethical violation. Often, the information found can help discern whether a particular story is true or perhaps part of a erotomanic delusion. However, if finding such information does not promote the care for the patient and only satisfies curiosity or other needs of the physician, the American Psychiatric Association Ethics Committee considers such behavior an ethical violation.12 Searching and gathering information on patients behind their back violates patient autonomy and dignity, breaking the trust established in the relationship.13 In essence, this information outside of the direct face-to-face communication may be detrimental to the therapeutic efficacy of treatment.

On the flip side, patients will often use search engines to find out more about their physician. Professional information is easily available on the Internet, and many of the physician rating sites glean information from one another. Much like ratings on Amazon.com for merchandise, physician rating sites are increasingly being used by patients, and they are among the highest hits regarding searches for physicians on many search engines. Other personal information is available as well, including mortgage deeds registries, marriage records, and criminal records in addition to social network sites.14 A meta-search engine, 123People.com,15 checks numerous sites and categorizes its findings into information clusters such as e-mail addresses, pictures, phone numbers, blogs, biographies, videos, Amazon wish lists, documents, and social network profiles. If the physician’s name is fairly common, such as “David Smith, MD,” relative anonymity exists as there are numerous physicians in the US by that name; however, if the name is quite unique, such as this author’s name, “John Luo, MD,” the majority of Web sites found are indeed accurate.

Recommendations

With regards to social networking sites, it is recommended that boundaries are maintained by not connecting to patients. This author has received numerous requests by patients who have found the social networking profile on both LinkedIn and Facebook. In order to not merely “reject” the request and the patient, which is subject to misinterpretation, an in-person discussion of privacy issues and an explanation of more appropriate methods of communication, such as e-mail and telephone, usually makes it understood that this boundary serves both patient and physician alike. Take care to adjust privacy settings on social networking profiles to reveal limited personal information or just professional information. Choose carefully what is posted to these more “personal” sites and to whom and with which organization one establishes relations. LinkedIn recommends that users only connect to people whom they really know.16

It is also helpful to survey popular search engines such as Google and Yahoo to find out what Web sites are most popular in a search. Use of quotation marks around the name help eliminate the Web sites that merely have one element. With Google, it is easy to setup a Google Alert for the physician’s name, which will then send an alert e-mail whenever that name is searched and which web site was utilized.17 If there is any content that is embarrassing or incorrect found on the search, contact the search engine and find out how to remove that Web page. Google has a Web page Removal Request Tool,18 which can remove pages that have a social security or government ID number, image of handwritten signature, bank account or credit card number, or your full name or business name on an adult content site.

To protect your professional identity, check several physician rating sites for reviews. If there is material which may be slanderous, some sites will remove any posting which has little critical merit; however, some sites merely tell physicians to post a rebuttal. For the technologically naive, there are numerous firms that will help scrub search engines and haggle with Web page owners to help establish a fresh online identity.19

One way to combat misrepresentation online is to create a professional website with links to appropriate sites such as Publications List, where writers can create an online profile of academic publications at no cost to individuals.20 Although search engines use different algorithms to determine relevancy, multiple links are still an important component of the ranking scheme. It also makes sense to purchase a domain name such as www.johnluomd.com in order to establish an online identity. Domain names and hosting are quite inexpensive, and numerous sites, such as Weebly,21  offer free tools to create the site without learning HTML code.

Conclusion

The trend towards finding all types of health-related information on the Internet will only increase over the years. Various technologies and Web sites such as search engines and the social networking sites make it quite easy for the paths of physician and patient to cross. However, just because information and relationships are readily available online does not mean they must be utilized or created. Boundaries and privacy do exist somewhat online, even though the interconnected web of the Internet ever so slowly shrinks that perspective. Just as with information overload, often times, less information is better! PP

References

1.    Fox S, Jones S. The Social Life of Health Information. Pew Internet & American Life Project. June 2009. Available at: www.pewinternet.org/~/media//Files/Reports/2009/PIP_Health_2009.pdf. Accessed October 13, 2009.
2.    MedHelp.org. Available at: www.medhelp.org. Accessed September 29, 2009.
3.    DailyStrength.org. Available at: www.dailystrength.org. Accessed September 29, 2009.
4.    Luo J. Health 2.0: what you need to know. Primary Psychiatry. 2007;14(8):31-34.
5.    MadKour, R. Family Outraged Over Teen’s Online Suicide. Available at: www.cbsnews.com/stories/2008/11/22/national/main4627448.shtml.&nbsp. Accessed September 29, 2009.
6. Paul R. Judge Rules TOS Violations Not a Crime in Teen Suicide Case. Available at: http://arstechnica.com/tech-policy/news/2009/08/judge-says-tos-violations-arent-a-crime-acquits-lori-drew.ars. Accessed October 7, 2009.
7. Cohen E. Should You ‘Friend’ Your Doctor on Facebook? Available at: www.cnn.com/2009/HEALTH/09/03/friending.your.doctor/index.html. Accessed October 7, 2009.
8. Thompson LA, Dawson K, Ferdig R, et al. The intersection of online social networking with medical professionalism. J Gen Intern Med. 23(7):954-957.
9. Guseh JS 2nd, Brendel RW, Brendel DH. Medical professionalism in the age of online social networking. J Med Ethics. 2009;35(9):584-586.
10. Jain S, Roberts LW. Ethics in psychotherapy: a focus on professional boundaries and confidentiality practices. Psychiatr Clin N Am. 2009;32(2):299-314.
11. Jain SH. Practicing medicine in the age of facebook. N Engl J Med. 2009;361(7):649-651.
12. Hughes L. Is it ethical to ‘google’ patients? Psychiatr News. 2009;44(9):11.
13. Yan J. Psychiatrists must beware the perils of cyberspace. Psychiatr News. 2009;44(4):9.
14. Gorrindo T, Groves JE. Web searching for information about physicians. JAMA. 2008;300(2):213-215.
15. 123People.com. Available at: www.123people.com. Accessed October 11, 2009.
16. LinkedIn New User Starter Guide. Available at: http://learn.linkedin.com/new-users/. Accessed October 11, 2009.
17. Google Alert. Available at: www.google.com/alerts?hl=en. Accessed October 11, 2009.
18.    Google Webpage Removal Tool. Available at: www.google.com/webmasters/tools/removals?hl=en. Accessed October 12, 2009.
19.    Banjo S. Washing Your Web Face. Available at: http://online.wsj.com/public/article/SB120320660446474003.html. Accessed October 12, 2009.
20. Publicationslist.org. Available at: www.publicationslist.org. Accessed October 12, 2009.
21. Weebly. Available at: www.weebly.com. Accessed October 12, 2009.