Saturday, 2 July 2011

Blurred boundaries for health professionals online...

The following exchange took place on Thursday night. @celticchickadee isn't my patient, and as far as I know, neither is the person, she is talking about. This exchange is very incomplete compared to how I would have handled this situation offline. I could just have said 'No, I don't respond to medical questions online'. But I didn't. Sooner or later, I'm guessing that a patient in my practice will start following me on Twitter. Perhaps there already are some. Should I interact less with patients than I would with another member of the public? I have a lot more questions about this but I'm interested in your thoughts. I post this as a follow up to my last one.

By the way, I asked @celticchickadee if she minded me blogging about this, as I realise that although our exchange was completely public this would amplify it a lot.


  1. Very interesting trigger for an ethics session ;)

  2. By coincidence, we were discussing a similar situation yesterday at work. We're rolling out an electronic system that may make it easy for junior doctors to unintentionally provide too much information on discharge to patients by directly importing radiology and pathology results into patients' discharge information.

    I say too much information, because our concern was that the patient might get information without the ability or background to contextualise it or a suitable information source to tell them how to interpret it.

    A query cancer case was the specific scenario discussed - where something suggests it, but the correct response is to await further tests or ignore spurious results; while the patient is obviously concerned and wants a definite answer. When one can't be provided, then they look for answers online with their incomplete information and hence queries like this.

    What's the answer? I'm more in the camp of trying to encourage the patientand their healthcare professionals to talk to each other but yes, it's a complicated minefield.

  3. Very interesting post.

    These blurred boundaries stretch beyond the realms of qualified healthcare professionals - as a student I get asked medical questions from friends and strangers, both on and off of Twitter, and I am always wary of how I respond.

    Whilst I am by no means qualified to give advice, and thankfully can fall back upon this excuse, I frequently find myself wanting to give some form of reassurance, and yet even this seems close to the dreaded grey area. For now, the best I can justify to myself is a point in the direction of some evidence-based patient information, and if that fails, I feel I can assure that a visit to their GP is always warranted.

    In your position, I would have done exactly what you did - after all, if you can provide a good quality of guidance through Twitter, are you not ethically obliged to do so?

  4. This person is clearly searching for the extra information she wished she had found out at the time. This exchange empowered her to know more about the problem. In this context you acted like a super google search engine.

    How would you have felt if she had told you that she was feeling depressed / in pain / nauseous ? Would you have continued this conversation via email or phone ? Should we first ask some more questions so that we have a point of contact if we want to follow something up ? As a gp I sometimes convert a telephone consultation into a face to face one so that I get a more involved consultation. I wouldn't want tweet consultations with my own patients.

    Conversely if I was at a party and had this conversation i would have do e the same as you / but I would have had the extra lines of communication as backup (nonverbal)
    The other point to make is around equity of access. Twitter is global. There could be scope for people who don't have easy access to doctors to gain something from these exchanges. It could open the floodgates ? It isnt wrong , its just something we havent encountered before so it feels weird . I think I would have found this more emotionally stressful as I coundnt see the patient. I wouldnt want these scenarios in my tweet account every day When would yousay no ?

  5. Even if we're doctors, we're still people and Twitter users. Although I'm a public health doc now, I used to be a GP. Recently somebody I followed on Twitter posted about a severe abdominal pain. I replied along the lines that she should consider calling an ambulance. The next day she posted that she thought something had burst, and then that there was blood.

    In a phone conversation I'd have bot clues from the tone of voice, the speed of speech; and I'd have been able to ask detailed questions to clarify the symptoms and e.g. aggravating factors. In 140 characters, with somebody I hardly knew, who may or may not have been particularly ill and might choose to ignore me, I felt anxious that she might have e.g. appendicitis or ectopic pregnancy. (I once diagnosed appendicitis in a relative's flatmate by phone when they hadn't wanted to bother a doctor other than a relative!)

    I ascertained that she was not alone, but with a boyfriend who could summon help if things got worse; and noted that she was tweeting about what she was eating, so unlikely to have an acute abdomen.

    I have wondered - should I have ignored the comments about her pain and the "something bursting"? They were made in her public timeline, not to me. If I'd ignored her, I couldn't be blamed if something had gone wrong, could I? And by responding, could I be blamed if I said something intending to mean "don't panic or get too alarmed to think straight" but which was interpreted as "he say's I'm OK so I don't need to call an ambulance or anything? Or did I (by commenting that she would be well advised to call a doctor or NHS Direct, and that I was not n a good position to make a diagnosis, and there was a possibility that it was something serious) wind risk alarming her unnecessarily and inappropriately?

    Of course, our conversation was in public; for all I know somebody else with an ectopic pregnancy was also wondering what to do and reading the exchange.

    Right now, I think I probably erred a little on the "too cautious" side; but that I got it broadly right.

    The exchange made me feel uncomfortable. But I wouldn't have felt comfortable ignoring her comments either. To think that somebody might have been describing the symptoms of something that could kill her, while I, knowing the possibility that she had a ruptured ectopic or appendicitis, failed to comment, seems worse than any risk from commenting.

  6. Thank you all for the comments so far. You are picking up on the complexities. This was in many ways a rather straightforward encounter... but others may not be so simple.
    This is the reality of being online...

  7. I think it is an important point to consider what your local college of physicians (or regulatory authority) considers the establishment of a doctor patient relationship. Certainly there are jurisdictions that might consider that exchange to constitute the establishment of a relationship (and all that entails with regard to responsibility for care and confidentiality).

    I'm not saying you can't interact with patients by social media, but you need to think about the downsides from the perspective of the folks who hold your license in their hands.
    Dr. J

  8. As a junior doctor, I really wouldn't be comfortable having the above twitter conversation. When a person asks me for a medical definition or some other innocuous sounding thing, I think what they really want is a definition, explanation, then my interpretation (which may differ from their own practitioner) and finally medical advice (which I am almost certainly less qualified to give than the expert with whom the person is in contact).

    In this case, I would have wanted to know who the person is with distant metastases, where their primary disease is, what they know so far, are they ready to hear the information I am going to give them?

    Then I would want to be able to answer the question - do I know enough to answer the follow-up questions when I open this can of worms!

    Am I being over-cautious.


  9. I think you handled this well. It's also worth saying that @celticchickadee did quite a legitimate thing in making this inquiry, and that it is only to be expected that this will start to happen a lot more. It doesn't say much for a profession if it is so timid that it recuses itself from less-than-ideal situations. With the substance of this having been discussed quite well so far in the comments, I don't have anything particularly to add at the moment to the issue. But I think that, running along side this, is another issue.

    Without wishing to sound complacent, and without turning a blind eye to Twitter's limitations, I think that all the intertextual and contextual content of speech is there on Twitter too. What's more, we are better at receiving contextual cues from Twitter and instant messaging than we think. It's not the phone, and it's not face-to-face, so we don't have tone of voice. But we do have speed of reply, and the number of replies per message. If someone is flustered and jumbled, we can see it.

    We do not tend to analyse these things; if we did, we would seem ridiculous. You can say you could hear fear in someone's voice, but people would be skeptical if you said you knew from someone's quick replies that they meant business. But, intuitively, we can get these clues. I do a lot of communicating this way - so does everyone else here - and it would be odd if we hadn't picked up some skills.

    And fundamentally, it is still language, and we can see when someone is hinting at something, as @celticchickadee was from early on.

    We cannot expect patients not to start doing this, and stonewalling them is counter-productive, and an immediate re-direct to offline sources of help counts as stonewalling. Fortunately, we are a little better resourced than we think.

  10. Interesting discussion! Brings me back to a discussion we had before though on whether to keep a separate account as a Dr from that as just yourself? Though being a healthcare professional is very much part of me. But if people are going to ask advice on line, will they take me seriously if half of my Tweets are about the cats latest catch of a mouse or bird, the hideous state of my daughter's bedroom, or even the struggles of our local football team?

    Like you I would have felt compelled to respond, but felt powerless not knowing the person, having few clues including no non verbal ones and no idea of why the info was being sought. It's a difficult one.....welcome to the modern world!


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