Breaking The Rules

A recent article called “To Tweet, or Not To Tweet: Physicians Misusing the Internet” discussed a new JAMA study which apparently found that…

“92 percent of state medical boards in the United States have received reports of [online] violations ranging from inappropriate contact with patients to misrepresentation of credentials.”

I guess this is supposed to be shocking, but I was really somewhat underwhelmed with the information (I was actually more shocked it wasn’t 100% – which state has had none…because that’s awesome). It’s exceedingly easy to report a violation that occurs online, since it’s permanently etched in the history of the internet, so of course there’s a large number of state boards receiving reports on violations that occur online.

The discussion is relevant and interesting, but clearly written with a negative attitude and watch-your-mouth, paternalistic tone (like many of the recent articles and research publications on social media in medicine, unfortunately). A quick search finds that the doctor on the answering end of this Q&A session has a rarely used Twitter account (@RyanGreysen) and no blog (that I could find, anyway)…clearly making him one of the least effective people to be discussing these issues unless his only advice is going to be to avoid a presence in social media all together.

However, that’s not exactly the point. What irks me so much about the recent onslaught of negative-nancy articles on physicians in social media is that they pretend that the internet is some delinquent hangout for the physicians who can’t seem to conduct themselves professionally. The tone of these articles comes across like Twitter is where we gather to join in HIPAA-violating hippie parties and have inappropriate contact with patients.

The tone implies that these things don’t happen on the elevator, at the football game or in the corner bar. The article (and many others like it) repeatedly discusses the need for educating physicians on the “rules” of online behavior and “how to conduct yourself online.”

That is not the problem.

The fact that the online world documents breaches is the problem.

Venture into any hospital hallway and you will be bombarded with far more private information in a circle around one ward than you will in a full days Twitter stream.

The issue is not that we’re gathering online and violating HIPAA because we don’t know how to conduct ourselves online, the issue is that it’s recorded here.

By saying we should educate physicians on how to act online we imply that either:

A) Unprofessional conduct is not occurring off-line.         OR

B) It’s more important to watch what you say here because it’s documented.


Is it important to watch what you say here because it’s documented?

Absolutely. Unequivocally. Yes.

Is it more important than it would be in your local Chili’s?

I sure hope not.


Sure, you’re less likely to get caught if you’re talking about private patient details in Chili’s, since it’s not being recorded and all, but that doesn’t make it ok. As a kid my mama would tell me,

“Doing something bad when you know you won’t get caught doesn’t make it any less bad.”

Doesn’t that rule still hold true?

What I’m saying is that these are not separate entities. Just because reports aren’t getting filed about physicians discussing private patient details in elevators as often as they are about physicians discussing private patient details online does not mean it’s happening less. It means it’s recorded less. That is not to say that there is no room for guidelines or advice about conduct in social media, just that online behavior is not inherently different than offline behavior. @SeattleMamaDoc really said it best,

“We are worse in the elevator than we are online.”

We don’t need to educate physicians on behavior online, because this problem is not unique to the internet. We need to educate physicians on keeping private patient information to themselves. On using some common sense and respecting co-workers and patients alike. Not just on the internet…everywhere…including on the internet. The physicians who are violating privacy and acting unprofessionally in the elevator are the ones who will talk about their patients online. This is not a problem inherent to an information medium, it’s a problem inherent to a person. And I’m not sure it’s one that can just be “educated” out of someone.

Thus, this is not about our online conduct, it’s about our conduct…and as soon as we make it about online conduct we imply that it’s only important to follow the rules if there’s a really good chance you’ll be caught if you break them.


Image 1: Pixomar | FreeDigitalPhotos.net

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10 Comments + Add Comment

  • Wonderful response to the negative tone of that article — I definitely agree with your sentiments.

  • Excellent article… Very “to the point” and very valid. Great work…
    Elevators and twitter… I love the comparison, because it is so true.

  • Nice post. There was a story the other day of a nursing assistant at a nursing home who was posting inappropriate pictures of demented patients online. One of the faculty at my institution said something to the effect of, “I wish that person had training about how to behave on the internet.” My response was that person essentially that person needed life training on how to act in a professional environment. Training about online behaviors will not really stop bad stuff from being put up online. Probably ten years ago, this nursing assistant would have been taking polaroids, and keeping them at home and no one may have found out about it. I see this as the same idea as your Chili’s example.

    In a weird way, having more online activity may help expose this unprofessional behavior and allow us to more effectively deal with it precisely because it is now being recorded. This comment comes with the caveat that all things must be looked at in context, of course.

  • Good post! I made a similarish point here- is the issue behaving badly or being seen to behave badly:


    • By the way @motherinmed and @kind4kids were also study authors so hopefully they will contribute.

  • Great post! I feel like (as with anything new), social media is going to be scrutinized more harshly that the old way of doing things. Of course, we need to tread lightly with social media in areas of privacy and professionalism, but I agree 100% that we shouldn’t just concentrate our efforts here because this is not the first time these issues have come up. It should be something that is discussed often and not so much in a condescending tone, but more-so in a way that stresses how to be smart about all interactions so we don’t compromise our patient’s privacy or our own.

  • Thanks for the post and I agree with aspects of your argument – especially that unprofessional is unprofessional, whether you are caught or not.

    However, I think there are ways that online behavior is inherently different than offline behavior. Sometimes, the goals of our interactions are quite different. The audience is different. Boundaries between professional and personal are more blurred. Cyber-dishinhibition is a known phenomenon. And, yes, the permanency of our actions can be very different, and therefore the repercussions.

    I’ve had a bad day at work and make an unprofessional comment about a consultant to a colleague, let’s say. I may look back at that moment and regret making that comment – it was unprofessional. We all do things that are unprofessional – we are human. So we reflect, think about how we want to be in the future, and move on. But, if I make that same comment on social media, the effect may be very different. It’s now a public discussion. That comment is part of my professional digital identity. It has more potential to hurt me, any parties involved, and I can’t take it back.

    Our research (Physicians on Twitter, JAMA 2011) showed that physicians are using Twitter to share health/medical information with each other and the public. My long view: There’s tremendous potential to effect positive change, yet, really, to see that to fruition means addressing online professionalism upfront. I think we need a foundation of public trust before we can build anything truly meaningful and lasting in “healthcare social media.” So, that’s where we are starting.

  • Thanks for sharing your frustrations, @daniellenjones.

    Can’t add much to the above comments of my eloquent friend and collaborator @motherinmed.

    We can all aim to be better in the actual and the virtual elevator. As for me, I aim to take the stairs more often…

    Not trying to catch anyone, nor to sensationalize. Describing what occurs is a first step in understanding it. In generating discussions like these.

    Let’s build and be in the community, recognizing who we are as individuals and as professionals, who we are representing, and who we serve.

  • Technology is growing. Social media is here to stay. As healthcare providers we do need to take a step back and understand some of the implications of our presence, our words, and our presentation. But, at the same time, we need to jump in. I conceptualize social media presence in 3 ways:

    1. Professional Development and Discussion: Sharing articles, blogs, and links. Discussing research, science, and clinical practice
    2. Public and Patient Information (general): Health information about conditions or health in general targeted broadly (I think this is where social media can have a HUGE impact. Go look at Dr. Oz twitter and some of the garbage he touts….but people will listen. Take reputation and good info and social media could be used to counter scams, quacks, pseudoscience, and bad info). Links, websites, articles, etc.
    3. Personal: I like craft beer, mountain biking, and coffee. Here is a picture of me at the park.

    Now, many (including myself) blend the above 3. On my social networks, especially twitter, I am mainly 1 with some 3.

    In social media, you can either target an audience or see who will become the audience…

    @MotherInMed “However, I think there are ways that online behavior is inherently different than offline behavior. Sometimes, the goals of our interactions are quite different. The audience is different. Boundaries between professional and personal are more blurred. Cyber-dishinhibition is a known phenomenon. And, yes, the permanency of our actions can be very different, and therefore the repercussions.”

    This sounds like a paranoid and scared view of social media. YES, what we say is permanent (there is seriously no such thing as deleting because of google caches). But, that brings an openness to the medium that is not present else where. Mistakes are caught, called out, and corrected quickly. And, mistakes will be made.

    For big organizations, goals and guiding principles need to be made. For individuals, don’t be an idiot. If you are looking to grow your social media presence roughly know your goals, audience, and who you would like to interact with.

    This article is very applicable:

    To quote:
    “The biggest risk in health care social media is NOT participating in the conversation. Simply putting “find me on Facebook” or “follow me on Twitter” badges on your website does not equate with health care social media. Having noted this, among the most common concerns that seem to limit participation are those regarding professionalism. So let’s make this as easy as possible, with 12 words to light your way:
    Don’t Lie, Don’t Pry
    Don’t Cheat, Can’t Delete
    Don’t Steal, Don’t Reveal”

    @MotherInMed stated:
    “I think we need a foundation of public trust before we can build anything truly meaningful and lasting in “healthcare social media.” So, that’s where we are starting.”

    As a physical therapist, just let me tell you >> YOU HAVE a foundation of public trust purely because you are an MD (or future MD) UNLESS you prove otherwise. Dr. Oz spouts some of the most non-scientific, non-evidence based info I have ever seen, but people will BELIEVE him because he is an MD. My view is that you do not need to build a foundation, you need to USE the reputation and foundation you already have as physicians.

    The more sane, caring, science minded, thoughtful physicians (and scientists and other healthcare providers) we have in social media the better. Better intra and inter-professional discussions will take place. Broader information will become connected. Bad info will contradicted. The public could be educated. Who knows, even CHANGE may be spawned.

    Follow me on twitter > @Dr_Ridge_DPT and let me know what you think….

  • Oh! it’s really true,But in my view there’s nothing 100% and nobody knows 100%, we all are crow in the cloud, so in my opinion we need to be happy as is. Thank you
    Gyanu Basnetg

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About The Author

I'm an ObGyn. I started this blog as a medical student (some would call that doctor school) and now I'm working as an Ob/Gyn, which is seriously the coolest job ever. I'm a twin mom and recently added a baby brudder to the mix. My life story through November 2010 can be viewed here. The events in the many years following can be summed up as wedding bells, books, exams, babies, and doctoring. I started this blog in hopes of landing a role in a Lifetime movie so I could quit medicine and move to Hollywood, but that hasn't happened...so if you wouldn't take medical advice from Angelina Jolie, you shouldn't take it from me. I may not even be a real person. In fact, I'm probably a spambot. Or possibly a 15 yo boy blogging from a dingy basement. If you're really interested you can read more about me here. If you have any questions or want to guest post contact me.

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