Medical blogs: Who are they good for?
■ Can physician-written blogs meet legal and ethical professionalism standards?
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Medical blogs can provide two benefits for the public. They can offer timely and accurate medical information as a supplement to what is available through other media. Perhaps more importantly, they enable members of the public -- often patients -- to express concerns about their health care experiences and to receive feedback from the bloggers and visitors who read their comments.
Writers to the blog can express their concerns fully because they are allowed to remain anonymous. Although many blog visitors comment on experiences they have had or anticipate having with their physician or physician's staff, most of them have not shared what they write about with their physicians, and, for their part, physicians rarely give patients the opportunity to talk about such matters.
There is no doubt that a lack of time and real and imagined power differences between physicians and patients, among other factors, contribute to inadequate communication. Medical blogs help compensate for the poor communication -- the anonymity, time and space to ask and say whatever one wants and the availability of immediate responses to one's comments make medical blogs a means of much-needed ventilation for many.
As an example of the role of medical blogs in the discussion of patient concerns, I'll tell you about my "Bioethics Discussion Blog," which, since 2004, has developed 600 topics related to the medical system, medical professionalism, medical education and ethics.
The most popular topic among visitors to my blog has been concern over violations of patient modesty. I have been aware of the importance of respecting patient modesty throughout my 50 years of internal medicine practice and never ignored it during many years of teaching the skills of physical examination to students. Only after reading more than 1,000 comments by visitors to my blog, however, did I become fully aware of the extent and magnitude of patient concern and distress.
Unfortunately, quantitative statistical analysis of blog responses is probably not realistic, but one can easily appreciate the qualitative aspects and nuances of patient concern for modesty. There are questions about respect for both unconscious and conscious patients during surgery, office procedures and physical examinations.
Visitors ask specifically how well the modesty interests of unconscious patients are respected in the operating room. What is the gender of the attendants who perform the surgical preps? What parts of the body must be exposed? Must genitals be exposed? What opportunities do patients have to express their concerns prior to surgery, and will their wishes be honored in the operating room?
In office procedures and examinations of genitalia, can the patient request that only attendants of his or her sex be present? Will that request be honored? The argument over right to choose the gender of physicians, nurses and technicians always arises. Most people feel that women are granted that right but men are not. Male visitors to the blog state that physicians either ignore their requests with seeming surprise or simply turn them down with an economic excuse or a "take it or leave it" attitude.
My visitors also have found that hospitals are generally uninterested or unable to change policies and employment practices to accommodate respect for patient modesty. Those who can't find a resolution for their modesty concerns write about postponing or disregarding necessary procedures or examinations.
Though my blog visitors are not my patients, and quantitative statistics are absent, I believe their concerns deserve professional and institutional attention. I tell them that, although ventilating on the blogosphere may be emotionally therapeutic, they may need to become more active in bringing about the changes they desire, and I encourage them to do so. At present, writers on the blog are discussing how to present their concerns to their doctors and hospital administrations. I have suggested they form groups of like-minded patients to advocate with those who can help change what they view as violations of their modesty. I think that my contribution of such advice is a legal, ethical -- and humanistic -- response. For professionals who moderate medical blogs, offering appropriate advice goes a step beyond merely providing discussion space.
Medical blogs, moderated with attention to civil and open discussion among the visitors and following guidelines for ethical operations, make a significant contribution to the medical education of the public and, I dare say, the profession.
Maurice Bernstein, MD, assistant clinical professor of medicine, Keck School of Medicine, University of Southern California, Los Angeles; blogger, "Bioethics Discussion Blog" (link)
Blogging allows average physicians to share their day-to-day frustrations with an audience. Too often, these frustrations are buried and left unsaid because physicians are too busy to advocate for themselves and, thus, lack a voice in a system that is falling apart.
By allowing readers to see physicians as they are -- normal people performing demanding jobs -- blogs can lower the unrealistic expectations that are the source of enormous stress in medical practice.
Despite these considerable benefits, physician blogging carries great risk, principally in these areas:
Professionalism: Many blogs, written like personal journals, vent anger and frustration toward patients, payers, colleagues and the system. This tone, and the tone of those who comment, can be inconsistent with medical professionalism.
Misrepresentation: Nonphysicians can represent themselves as physicians, and physicians can speak in areas in which they lack qualifications. If readers make decisions based on inaccurate information, this could result in significant harm.
Confidentiality: Physicians are legally and ethically bound to protect the confidentiality of their patients. In describing their daily lives and practices, physician bloggers must walk the fine line of characterizing cases accurately without breaking patient confidence.
Disclosure: The goal of many Web sites is to sell products. Commercial Web sites have portrayed themselves as medical bloggers, hoping to exploit public confidence in the profession to make money.
Reliability: Blogs are not peer-reviewed, most are not edited, and statements are made without citation of sources. Many readers assume these statements to be true without checking facts, but the data are only as reliable as the physician writing about them.
Many medical bloggers remain anonymous so as not to be held accountable to professional standards or expose themselves to the possible repercussions of their public statements. Others write anonymously because they work in institutions that fear the potential liability of physicians "baring their souls" in public.
Given these facts, is it possible for a blog to meet the expected standards of the profession while not silencing the voice of the average physician?
The answer is "yes," if the physician blogger holds to standards that are higher than those for other bloggers. This is the purpose of the Healthcare Blogger Code of Ethics -- a set of principles that clearly state the standards to which the blogger intends to adhere (link).
These standards include:
Perspective: A clear statement of the qualifications of the blogger.
Confidentiality: A commitment to stay within legal and ethical bounds of the confidentiality pact between medical professionals and patients.
Disclosure: Up-front statement of commercial interests related to the content of the blog.
Reliability: Backing up statements with sources when possible and correcting misrepresentations if any are found.
Courtesy: Holding to the behavioral standards of the medical profession, not allowing or engaging in libelous or injurious statements.
The HBCE community, a collection of physicians, nurses, allied health professionals and patients, put the principles together in response to well-publicized missteps by medical bloggers that put the integrity of all medical bloggers in question. The purpose of the code is to reassure our readers that we are who we say we are, to reassure our patients that we won't expose personal information and to reassure our institutions that we are meeting their legal and ethical standards.
The code is shared with bloggers who are reviewed and approved by the HBCE community. Approval status is not given to new bloggers until enough work is available to establish the blog's reliability and consistency with the principles of the code.
The code is not enforced per se, but members who have deviated from the code have been reported by other bloggers.
One of the greatest benefits of having a code of ethics is protection of anonymous bloggers who are writing responsibly. The code also offers reassurance to institutions that their medical students and employees are addressing potential legal and ethical risks.
Nevertheless, blogging will always be associated with some risk because it contains personal reflections of the author.
Simply having a code of ethics will not prevent misuse of the medium, and even blogs by conscientious writers attempting to abide by the code should be read with caution.
Physician blogs should not be seen as an attempt to replace other sources of information, but instead as a new kind of medium -- a view into the minds of the rank-and-file members of medicine.
Used properly, blogs can give voice to a group that has often felt powerless to affect change. Ultimately, the responsible use of this medium lies with the blogger.
Rob Lamberts, MD, internal medicine/pediatrics, Augusta, Ga.; blogger, "Musings of a Distractible Mind" (www.distractible.org)