Wednesday, March 9, 2011

Docs behaving badly in social media

A recent research letter in JAMA surveyed more than 300 high-profile (500 followers or more) physicians on Twitter and reported results of a "content analysis" of more than 5000 of their individual tweets. As one might expect, about half of the tweets were related to health and medicine; another 20 percent were classified as "personal communications," and 12 percent were classified as "self promotional." I would be interested in knowing how @MotherinMed (internist and medical educator Katherine Chretien, MD) and colleagues determined whether or not a tweet was "self promotional" - would posting links to my blog posts count, even though I have no products to sell?

At any rate, the study's major finding was that about 1 in 30 tweets were classified as "unprofessional," a category that included patient privacy violations, potential conflicts of interest, profanities, sexually explicit material, and discriminatory statements. This finding is consistent with prior reports on online professionalism and the content of medical blogs that led the American Medical Association to release a guidance statement on professionalism in social media last November. Chretien and colleagues reasonably conclude that health professionals may require more education about appropriate behavior on social media sites.

But to play devil's advocate, is this really necessary? That 3 percent of tweets were "unprofessional" seemed to me a surprisingly low figure, given the great potential for abuse inherent on Twitter, where most accounts are at least semi-anonymous and few online identities other than those of celebrities are actually verified by the company. If I visited a large sample of office practices or hospitals and recorded all health professionals' conversations that were loud enough to be overheard, I suspect that at least 3 percent would probably meet the definition of "unprofessional" that this survey used.

For several weeks I followed an anonymous family doctor on Twitter who would tweet funny observations about patients whom he or she saw throughout the day. No identifiable patient information was included, but these observations were frequently unflattering, and occasionally downright insulting. (One reason I suspect that many physicians love to watch the TV show "House" is that the main character routinely says things that we know we could never actually say out loud to patients and get away with.) This Twitter doc had a large following, many of whom also appeared to be practicing physicians who "tuned in" to this reality show-style channel for a daily dose of humor at the expense of anonymous patients.

Eventually, I tired of reading these tweets and hit the "unfollow" button. But the question remains: does this Twitter user's behavior cross the line? Should he or she be formally reprimanded for "unprofessional" behavior and instructed to cease and desist? And if so, why?


  1. Nice, thoughtful post on this topic. Some of my responses:

    We coded tweets as unprofessional if tweets were promoting any content by its author: including blogs, appearances/interviews, books, etc.

    I think there are a couple of important differences between unprofessional content being posted on Twitter versus overheard in a doctor's office: 1) scale- tweets can be re-tweeted and seen by many more than an overheard office conversation; it's a public message 2) permanency- tweets are digitally archived by the Library of Congress (i.e. they can be used against you anytime in the future).

    Re: the anonymous family doctor tweeting offensive things about patients, it is somewhat of a gray area because while I think many physicians (and the public) would find that behavior unprofessional and offensive and a poor reflection of the medical profession, no laws are being broken. Ethically, this person is not placing the welfare of his/her patients above his own need to entertain and deride. But, there's also a question of whether pt privacy is being violated. Even though he/she is supposedly anonymous (which is arguably impossible to be truly anonymous for long), could patients still identify themselves in the description of the encounter, particularly given the real-time tweeting nature of his/her patient log? If so, that would be a greater/more urgent argument for someone to say/do something about it.

    The question is who?

    Ultimately, when we're dealing with pt privacy issues or conflicts of interest involving potential patient harm, I think we have to act as a profession to protect patients. Whether we want to go a step further to protect the profession --the jury's still out on that one.

  2. Hi Katherine and Kenny

    I do not think that posting links to blog posts is unprofessional if you are wanting people to read what you've said on your blog in order to pass on information, seek advice or make connections. cheers Sarah (midwifery educator, New Zealand/Australia)

  3. Personally, I don't think that we have much evidence that the public has a view on the 'profession' has a whole, and are more likely to consider poor behaviour as reflecting on the individual, or as someone pointed out on the #nhssm chat tonight, the organisation that they work for.

    I completely agree with Katherine's comments that awareness of the patient's interests comes first. Everyone else comes after that.

    It's interesting that this is a similar view to medical students views on online professionalism (

    I guess I am a little surprised that linking to blog posts was classed as self-promotional, but I suppose that was difficult for you to categorise.

  4. Great post. It seems to me that I too follow this same unprofessional doc. It actually helps keep my profession in perspective. I try to be as polar opposite as him as I can, and in doing so may make me a more caring physician...Keep your friends close, and your enemies closer.

    I find it even more interesting that the Library of Congress is digitally archiving Twitter posts (is this really true, Katherine??? wow). I doubt he would be so glib if he knew this.

  5. Thanks for reflecting further upon our study, Kenneth! As a co-author (who wasn't on Twitter at the time of the study), I would clarify that we coded whether of not tweets were self-promotional (12% were) and also coded tweets as to whether they were unprofessional (3% were) and further subdivided that 3% unprofessional into the following: profanity or surrogate, potential pt privacy violation, sexually explicit, discriminatory, or other unprofessional. But self-promotion in and of itself was not de facto coded as unprofessional. Have I described correctly, KC?

    Thanks for discussing! Newly tweeting at @Kind4Kids

  6. In response to ryanmadanickmd (above) yes check it out April 15, 2010 Twitter Donates Entire Tweet Archive to Library of Congress

  7. Thanks for the stimulating post, Kenny. I agree with you that 3% is low on the unprofessional tweets. Surprised that only 12% made the self promotional category since lots of folks are bringing focus on their blogs and their locations and their breakfasts, etc. It's nice that people in our profession are perusing the social media and reporting on our behaviors. Thanks to the study authors. Blog On! Tweet On!

  8. Terry is right: our classification of a tweet as "self-promotional" was separate from the unprofessional coding (although the two could co-exist). What really bugged me were the tweets promising cures to cancer or fibromyalgia by purchasing a product on their site or medical statements that were just off the wall wrong. This is where accountability is badly needed.

  9. Try Doc Martin (PBS series available on Netflix) for all the things you'd love to say and get away with as a primary care doc!