Doctors, Identity, and Social Media. A Crisis or a Kink?

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A new platform, a new potential — a new potential problem. Tweets, blogs, posts, “many to many” e-communications have created fears over doctors having an online voice within a public domain.

For all health professionals, social media poses an opportunity and a challenge.

Fast and free, many-to-many messages enable engagement within communities, with patients, and an opportunity to set the health record straight in a misinformed media.

This new e-voice comes at a cost. By its very nature, the internet is a disobedient arena. A cause for concern for reasons highlighted by researchers at John Hopkins University –

  • messages can spread with little control
  • boundaries can blur
  • mini blogging misdemeanours are open to public viewing at best, public sharing at worst

Official guidelines by the American Medical Association (AMA) advise physicians to consider a double online identity; one professional and one private.

Not since the strange case of the troubled Dr Jekyll has a doctor been subject to grapple so with their identity. The 21st century physician faces a far less odious and much more common conflict; to jump in with all 10 digits as a professional doctor, or as a Mr/Mrs/Miss/Ms, or not at all.

Identity Crisis or Kink?

John Hopkins University associate professors researched the modern day dilemma of doctors tweeting in a recent article in the Journal of the American Medical Association; “Social Media and Physicians’ Online Identity Crisis.

The team, Mathew DeCamp MD, Thomas W. Koenig, MD and Margaret S. Chisolm concluded in favor of doctors having an online identity within their professional capacity, rebuking guidelines to manage a double persona. The reasons put forward for engaging within social media as a professional health practitioner include –

⦁ to have two separate identities online is impossible. People can connect the “professional” you with the “personal” you in a snap

the positive impact of doctors tackling misleading medical information outweighs the potential pitfalls

opting out of the online conversation is not an option. Engagement is a must.

The recommendation by the American College and Federation of State Medical Boards (FSMB) to have two identities is impossible according to the John Hopkins team, simply because “with minimal information, searching the web can quickly connect professional and personal content.”

Dr Jekyll was never a good advocate for doctors dabbling with more than one identity. Even in the less curious of cases, managing dual identities is hard work and according to John Hopkins’s research team, essentially “operationally impossible.”

As any good Careers Counsellor will tell you, the professional self is an extension of the personal; a complex interplay of everything that makes us individuals with the allsorts that adds meaning to our lives.

To divide the two would be a separation “verging on the nonsensical,” researchers conclude.

People are not just their jobs. As one Doctor, dying and intending to tweet from her death bed to normalize the death process demonstrates in her Twitter biography. Not just doctor, but patient too –

Wife, daughter, sister, aunty, friend, doctor, patient and author. Always trying to look on the bright side of life…” Wakefield · theothersidestory.co.uk @grangerkate

What Tweets?

Dr Katherine Chretien, an Internist at the Washington DC VA Medical Center looked into the content of doctors tweets by analyzing 260 Twitter accounts. To be included in the study, each doctor had to have at least 500 followers.

A total of 5,000 tweets were analysed. The last 20 tweets of each user sent between May 1st and May 31st were categorised by Dr Chretien’s team as either “health related”, “personal” or “inappropriate.”

Agreement was implicit in 78% of cases. Of the tweets that were classified by a tweet judge as inappropriate, consensus was sought in the team to confirm the original moderator’s suspicion of a tweet.

The results were published in JAMA. Of over 5,000 tweets –

  • 49% (2543) were health or medical related
  • 21% (1082) were personal communications
  • 14% (703) were retweets
  • 58% (2965) contained links
  • Seventy-three tweets (1%) recommended a medical product or proprietary service
  • 634 (12%) were self-promotional
  • 31 (1%) were related to medical education

One hundred forty-four tweets (3%) were categorized as unprofessional, of which –

  • Thirty-eight tweets (0.7%) represented potential patient privacy violations
  • 33 (0.6%) contained profanity
  • 14 (0.3%) included sexually explicit material
  • 4 (0.1%) included discriminatory statements.

You can very quickly match doctors with their content, according to Dr Kathleen Chretien and her research team.

“Of the 27 users (10%) in our sample responsible for the potential privacy violations, 92% (25/27) were identifiable by full listed name on the profile, profile photograph, or full listed name on a linked Web site.” Dr Kathleen Chretien comments in the JAMA article.

Still, It’s Good to Tweet

The John Hopkins article however would argue perhaps that despite the 3% of tweets being classed as unprofessional, physicians active on social media object to giving up an e-voice for exactly the same reasons that others argue it should be quashed.

The article highlights that social media by it’s very nature –
> blurs boundaries
> levels hierarchies
> leads to transparency

One self confessed twitter user would agree. Lisa Rodrigues CBE, NHS Chief Executive urges senior medical staff to tweet because “it is just a new way of communicating. It’s free, it’s easy and it’s totally in your hands.” Lisa Rodrigues, NHS Executive and CEO Sussex Partnership Trust.

Lisa adds, “Social media is just another way to network. And good leaders must be great networkers. Otherwise how can we learn, keep in touch with our own people and share what we are thinking or doing to help the people we are here to serve?”

Lisa’s reasons for using Twitter include –

1. To share good news, in 140 characters and via links to my weekly blog or other things on our website

2. To talk about the difficult stuff – such as when we make mistakes, or the stigma our patients, and our staff, face on a daily basis

3. To make contact with people whose ideas or chutzpah I admire

4. To hear about and discuss new ideas

5. To encourage and motivate people – myself and others

6. To signal change or challenges such as the impact of the recession on the NHS

7. To talk about trivia (eg *The Archers) * a popular UK radio serial

8. To hone my writing skills – you would be surprised what an improvement using 140 characters can make

9. To show I’m human

10. To say what I’m thinking without anyone editing it or giving it their own spin.

My name is @LisaSaysThis and I am a Twitter addict.

Social or Asocial Media?

Regardless of our position we should all tweet with care. For a doctor to ignore the online conversation is not an option. To juggle a professional and personal online voice is up to the particular tweeter, as long as they are aware that there is no guarantee that their professional identity is concealed. Armed with a wireless connection, anyone can quickly track you to your professional persona.

The real question is why wouldn’t you tweet/blog? The internet is the 21st century information party where everyone is clambering for health information. It’s where patients are answering their health questions, rightly or wrongly. Nibble a volauvent and rely, as John Mandrola suggests on common sense to see you through, but just make sure you are there –

The bottom line is always the same. Success comes from mastery of the obvious. Common sense, decency, truth and admitting one’s mistakes will rarely steer you wrong” John Mandrola is a cardiologist who blogs at Dr John M.

Notes:
John Hopkins University: Social Media and Physicians’ Online Identity Crisis
Social Media JAMA article (link)

Dr John M, Heart Rhythm, Medicine and Health
www.drjohnm.org
Blog of Dr John Mandrola: Commentary on electrophysiology, atrial fibrillation, healthy living, cycling, and knowledge.

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Patients lose trust in “scruffy” UK doctors, or do they?

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The visual tell tale signs of a hospital doctor – long sleeved shirt, tie and white hospital coat banned in 2005 as part of the infection control measures against the spread of MRSA and C.difficil has led to patients apparently losing trust in “scruffy” NHS doctors.

According to critics, doctors no longer look like doctors. One anonymous consultant told the Sunday Times —

If you come to see a consultant, you will be greeted by an open-neck-shirted doctor who will look as if he is the hospital DJ, but will in fact be the consultant.”

Dress code

In a bid to reduce the spread of MRSA and C.Diffficil, the NHS introduced a dress code banning ties, long sleeves and “superfluous” clothing.

The only “safe” dress options for doctors were scrubs and open necked short-sleeved shirts. A Dickie bow tie seemingly the only item at a male doctor’s disposal to set himself apart from the hospital DJ.

At the same time as the dress ban, a host of initiatives were introduced as part of the infection control measures including;

  • hand washing
  • sanitizers and gloving
  • linen handling
  • environmental cleaning
  • increased hygiene reporting

MRSA and infection control

MRSA, a “staph” germ, is the only staph strain resistant to first line antibiotics. Typically spread through physical contact, once entering the body MRSA can spread to bones, joints, the blood, the lungs, the heart, or the brain.

Serious staph infections are more common in a weakened immune system; patients most vulnerable are those in hospitalized for long durations, on kidney dialysis, cancer patients or those who have had surgery within the last year.

The Health Public Authority (HPA) now publish MRSA and C.difficile infection data for every hospital each week. Mandatory surveillance now also includes figures for MSSA (Methicillin-Sensitive Staphylococcus Aureus) and E.coli infections.

The infection control measures of 2007 have so far been successful. Instances of MRSA cited on death certificates has fallen by 77 per cent:

In 2007 – a total of 1,593 cases of MRSA were recorded on death certificates.

By 2011 – only 364 cases of MRSA were recorded on death certificates.

Critics

Critics of the dress code are however not convinced that the dress ban has had any proven effect. Dr Stephanie Dancer, medical microbiologist in NHS Lanarkshire and member of working groups on antibiotic prescribing, MRSA and hospital cleaning, speaking on Radio 4 to Mark Porter on Inside Health commented –

“Yes figures of MRSA – certainly we have seen figures for those plummet, but to say that is attributable to the dress code? No, I don’t think we can say that. I don’t think there’s any evidence to support that.”

Dr Dancer added that is is not the lack of doctors in ties that has reduced infection rates, it is instead the result of a “bundle” of initiatives introduced since 2007. The compulsory scrubs she claims have simply “eroded the doctors status.”

NHS “v” private hospital

Mark Porter on Radio 4’s Inside Health noted the “transformation” seen in doctors attire depending on whether they were working within a NHS or private hospital. The very same senior doctors seen working bare below the elbow for the NHS will “transform into full pin stripes” for consultation work in private hospitals. Dr Stephanie Dancer added –

If the suit is good enough for the private hospital, it’s good enough for the NHS.”

Will the US follow suit?

Unlikely. In the US, the American Medical Association (AMA) considered adopting a similar UK dress code in 2009. A proposal for a “no hospital coat” policy was scrapped after US doctors voiced heavily in favor of keeping their traditional hospital garb. Dr Mark Hochberg, a professor of surgery at NYU’s Langone Medical Center claimed that a physician wearing a white coat was a symbol of 20th century medicine.

The US debate was policy free, but not mirth free with many suggesting the bare option, started by “Anonymous” on the “Not Running a Hospital Blog”

Anonymous said…

I guess, if we are going to be absolutely safe, doctors should be naked.”

Doctor’s prognosis

What do doctors think? Opinion is divided. However, Dr Jonathan Afoke, Cardiac Surgery Registrar at Leeds General Infirmary commented that his identity as a doctor had nothing to do with his dress code.

Appreciating the need for basic professional attire and a personal tendency to opt for a pressed shirt and trousers, Dr Jonathan Afoke felt that the role of being a doctor was summarized aptly within a quote from a patient —

I had all these strange people I’ve never met see me every day, but I always knew that you would sit down with me and my family every day to explain things, so you’re my doctor.”

Hippocrates set out principles 2,500 years ago for doctors to adhere to, much of which makes up the professional code of conduct for doctors today. One notably reminds the practitioner to remember that the patient is a human being —

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being”

For this, you don’t need a hospital white coat, shirt, or Dickie bow tie.

Notes:

NHS dress code recommendations
http://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdf

Hospital Infection figureshttp://www.hpa.org.uk/NewsCentre/NationalPressReleases/2009PressReleases/090910MRSAandCDifficilecontinuetofall/

Radio 4: Inside Health
http://www.bbc.co.uk/search/?q=scruffy%20doctors

Not Running a Hospital blog spot
http://runningahospital.blogspot.co.uk/2007/09/tie-one-on.html

“The biggest shape up since 1848.” UK doctors to be assessed ‘fit to practice’ every 5 years.

Medical bag

Over 250,000 doctors held on the General Medical Council’s (GMC) registry will now be required to ‘revalidate’ –a new system of checks introduced to prove that they are up to date and fit to practice.

In the pipeline for many years, the proposal for revalidation was announced as a legal requirement in October 2012 with every general practice and hospital doctor in the public and private sector expected to be revalidated by the GMC by 2016.

To revalidate, a doctor must first be put forward by a responsible officer, usually a senior member of staff. A positive recommendation for revalidation will be granted when the responsible officer is satisfied that the doctor is actively engaged in the appraisal practice which includes;

–          proof of continual professional development

–          a review of incidents, complaints and compliments

–          35 supporting statements from patients and staff

The appraisal is based on Good Medical Practice; the GMCs core guidance for doctors which all registered doctorsmust adhere to. The main principle is to “show respect for human life” and make sure that their practice meets the standards expected in four domains;

1)    Knowledge, skills and performance

2)    Safety and quality

3)    Communication, partnership and teamwork

4)    Maintaining trust

The revalidation of doctors is the biggest change since the GMC published its first medical register 150 years ago. The GMC hopes that doctors whose practice raises concerns will come to their attention before a complaint is made. In 2011, complaints about doctors made to the GMC reached their highest with over 8,000 recorded complaints. During piloting and testing of the revalidation system concerns were raised over the performance of 4.1% of doctors.

Doctors have never before been required to prove their competency after successful registration on the medical register. Despite many professions required heavy assessment, many doctors have led 40 year long careers without ever having their skills and practice formally assessed after their initial registration.

Chair of GMC was the first to revalidate said that “‘I am delighted to be the first doctor in the UK to revalidate. This is the biggest change to medical regulation since the GMC was established in 1858 and change always brings some uncertainty to those it affects. However, to my medical colleagues I’d say that in this age of transparency our patients will expect nothing less.”

Notes:

Revalidation of doctors –

http://www.gmc-uk.org/news/14243.asp

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Do you know what to expect from your doctor? First ever guide for patients published by the GMC.

“What to expect from your doctor: a guide for patients” covers the standard of conduct that patients should expect and highlights the duty of doctors to make patient care their prime concern.

The new guide is based on the principles of Good medical practice; the GMC’s core ethical guide for doctors. Distributed to the 250,000 doctors on the medical register and used as a basis for medical standards in 14 countries, the guide is the main resource for registered doctors. Adapted from this publication, What to expect from your doctor explains the key duties of a doctor and covers patient concerns including;

What will my doctor tell me?
Training students and doctors
How doctors must use resources responsibly
How doctors must treat you with dignity and respect
The need for doctors to appraise their practice

The emergence of the guide is in response to the findings of the recent inquiry report into Mid Staffordshire NHS Trust which called for patients to be ‘put first.’ The trust was at the center of a major health scandal after it was found that up to 1,200 patients may have needlessly died from routine neglect. The subsequent inquiry led to a number of recommendations outlined within the Francis report in which Robert Francis QC calls for a service that ‘puts the patient first.’

Last year, the GMC reported that complaints by patients about doctors had hit a record high with 8,781 separate complaints recorded in 2011; a 23% increase in complaints from 2010. Among theses complaints, a significant number were in relation to how doctors interacted with their patients. Complaints about the communication of doctors had increased by 69% and complaints relating to a lack of respect rose by 45%.

Whilst recognising the medical professionals who have good relationships with their patients, Health Minister Dr Daniel Poulter commented in a statement to the GMC that there is much room for improvement;

‘The vast majority of doctors have an excellent relationship with their patients. However, the Francis report highlighted that there is much more we need to do to put patients at the heart of healthcare,” Health Minister Dr Daniel Poulter.

A revised version of the core guide for registered doctors was published on 25th of March and is currently being made available to doctors.

Niall Dickson, Chief Executive and Registrar of the General Medical Council commented to the GMC Press Office that doctors are responsible for a patient receiving both good medical treatment as well as compassionate care;

“The updated guidance for doctors makes clear that their responsibility goes beyond providing good clinical treatment – the doctor must take a lead role in making sure that patients receive high quality compassionate care.”

Notes:
What to expect from your doctor: a guide for patients –
http://www.gmc-uk.org/guidance/patients.asp?WT.ac=WBPR130423

Good medical practice (available online)

Source: General Medical Council News
http://www.gmc-uk.org/news

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