Wednesday, 8 February 2012

Would you block your patient on Twitter?

Road Block by PSP Photos
Road Block, a photo by PSP Photos on Flickr.

This question came about because I had tweeted a link to some research which had shown that 1/3 of practicising physicians, who responded to a survey (with a 14% response rate)  and said they used Facebook , had been issued with a friend request by a patient or their carer. This was much higher than the level reported in more junior doctors and medical students.

So should doctors refuse friend requests from patients? I have never had a Facebook request from a patient but if I had I would explain that I keep that account for close friends and family. A Facebook request can just be ignored which is an essentially passive act.

But I wouldn't block a patient from following me on Twitter. My Twitter presence is not orientated towards patients but I don't think that they would find anything shocking or surprising in my tweets. It would give them an insight into what I do when I am not in the practice. I consider that patients, or colleagues or students might read everything that I write here or on Twitter or anywhere else publicly online so I wouldn't worry about that.

A few people did think that patients should be blocked however. We discussed that this wouldn't necessarily stop them accessing the tweets as one only has to look at the profile instead. And blocking someone on Twitter is quite a hostile and aggressive act. I think I would find it hard to explain why I was doing that. One doctor said that he had blocked a young, female patient from his Twitter account because he wanted to set clear boundaries.

Another option, as the BMA guidance on the use of social media suggests, is to consider protecting your Twitter account and only allowing approved followers to see Tweets. In my experience the vast majority of doctors in the UK do have public accounts and I don't know if patients accessing tweets is a factor for those who choose to protect their accounts.

And how would I respond to a patient asking me for information on Twitter? Say they asked me where was the best place to find information about diabetes? Well, I would reply and point them to some good sources of information. And what if they were to ask me about their medical condition? If they were following me I would send them a DM advising that I can't give medical advice on Twitter but to get in contact with me in the surgery. I'd also advise them that their tweets are public and that that they might want to be careful about sharing sensitive information so it might be best to delete them. Normally I wouldn't send a DM to someone who I was not following as they would not be able to reply. But I think that in this case it might be the easiest way to deal with the situation. I wouldn't feel comfortable talking to a patient about a medical problem in 140 chtrs even if they were private messages. Essentially, I would treat a patient no differently to any other person I meet on Twitter. And since many people do not use real names on Twitter, and I have no way of remembering the names of all the patients registered with our practice it would be an impossible task to block all patients anyway.

I wouldn't follow my patients on Twitter. But perhaps I will change my mind about this. Perhaps following people from the area could give me better insights into what it is like living in the area and how I might be a better advocate for the community. Have no doubt however that the digital divide is real. A few weeks ago we were having a #nhssm (NHS social media) discussion on using video services such as Skype with patients when Evan Hilton, the executive director of Gofal, the Welsh mental health charity tweeted about the issue of digital in/exlusion in the South Wales valleys. He followed it up with this statistic:

Our patients face many challenges (often beyond their control) in staying health or living with illness. We haven't yet figured out how social media can be best used to help them but perhaps there is a case for not putting more blocks in the road. What do you think?


  1. Clear boundaries as a male GP when dealing with young female patients are in my view vital to keep both parties safe.

    I have told that this is a hostile act and 'uncool' but I would prefer this than being seen as inappropriate and overfamiliar in the world where one accusation can cause media attention, reputational damage and even a trip to the GMC.

    Maybe I am wrong but I prefer to be safe in my relationships and provide clearly demarked boundaries from the outset. I think it is slightly different for secondary care doctors as their relationship is different (except possibly psychiatry where they deal with the emotionally vunerable as well)

    This may be different for female GPs.

  2. James, I think the issue is that FaceBook and Twitter are markedly different platforms. In FB the relationship has a certain symmetry, that both parties buy into. You choose who to friend and who to ignore (or de-friend). The Twitter relationship is not like this at all. Twitter is essentially a broadcast to the world - anyone can see your tweets, be they patients or not. People don't have to follow you to see your tweets (unless your account is protected, in which case I have to say the meagre "point" of Twitter becomes even more diluted).

    In effect, if you are a male GP and you have a young female patient, she can see your tweets without following you anyway - even if you block her. All you're doing by blocking her is not allowing her to tweet back at you. Her following you does not create any reciprocal obligation on you to follow her back, or to take her into account (any more than we as professionals should always do anyway, arguably) when you tweet.

    Similarly, even if you follow her back, this is not establishing a relationship - it merely makes her tweets show up on your timeline. You can quit following any time, and that's no slight. It's completely different from the FB issue.

    However, if you actively *block* a patient, you're actually putting her at a disadvantage compared to your other patients (young female and other), who have had the savvy simply to search your tweets from the search bar rather than adding them to their timeline - I would be concerned that a "block" may be taken the wrong way, and construed (however incorrectly) as a slap on the wrist.

    I think the key thing here is that as professionals using social media, we need to be acutely aware of our responsibilities and the signals that our activities send out. That's not different per se from other members of society - it's the case for everyone. Communication is for communication, so we just need to be careful that what we say is fully defensible and that we tweet others as we would have them tweet us.

    I'll maybe put some more on my blog as I agree with AM that this is important territory (you're welcome to come and play over there too btw ;-)


  3. BTW, AM, I would have thought you'd want to use a more homely image for this post from our own recent past in NI ;-)

  4. Well done Shane for thinking this through and giving what looks to me like a good steer to your professional colleagues, many of whom are less knowledgeable than you about this brave new world of social media and are still finding their feet.

    You wonder whether following some patients might give you valuable insight - Yes! I'm sure it could. Why not give it a go. The glorious benefit of social media is that it allows us to share and access a wide range of perspectives. it broadens our horizons, it can create unexpected connections. Considerable value can sometimes be gained.

    Too often doctors and patients have this tendency to see each other as almost two different species. In fact we are all human beings with a shared goal of increasing wellness. If we recognise that fact, social media gives us a platform to explore new ways of listening to each other and sharing just a little bit more.

    Respect for boundaries is not rocket science, applying simple common sense and courtesy to each other is all that's required.

  5. eek! apologies Anne Marie - I thought both the original post and Shane's comment were by him. Oops. So my comment is addressed to both of you!

  6. Shane,
    I have to say that if this is what is expected in the brave new world of twitter then I will need to seriously consider disengaging and locking it to prevent causing unintentional insult, I locked down facebook after a patient contact.

    As a GP you are much more involved in the lives of your patients dealing with family and emotional issues and having ongoing responsibilities and you have to have a professional distance. The individuals who contacted me have both fallen into this category. Like it not these patients may misinterpret the relationship particularly in this context and you need to be extremely careful.

    In secondary care the relationship is different and so your perspective may reflect this.

  7. As a female GP my perspective is that I agree with Anne. I'm on Twitter precisely because it is a public platform. Its different to FaceBook, which is a more intimately, interactive platform. Shane's right. We should tweet others as we wish to be tweeted & always be aware that because it is a public arena we need to be responsible. Gender issues impact differently for individuals, depending on their perceived vulnerabilities, I might be worried about someone knowing intimate details about me, whereas a male GP may worry about someone revealing intimate details to them. It is not possible to know who's reading your tweets, so assume anyone is & tweet accordingly.

  8. I think it all depends on the tone and the purpose of the Twitter account. When I worked as an RMN if I had had a twitter account as a staff member it would have been written in a tone and with the purpose of being open source. If as a NHS member if staff talking about the SYSTEM as yourself and you're blocking patients I suggest that you may not have set the tone correctly. I created another twitter account to allow me to tweet about things more personal to me instead of using the Twitter account of the mental health charity I work for.
    When I worked for the NHS (9 months ago) we had quite a strict social media policy and I would imagine that most trusts do.

  9. Brilliant blog post and i agree with Anne Marie - essentially if a patient stopped and asked me in the high street about where to find information about hypertension I would point them in the right direction ... I have now doubt about this at all. However if that same patient wished to come into my home to discuss their blood pressure I would very much draw the line. Twitter is a very public space where we can encounter anyone much like the high street and Facebook is a much more private environment like our homes. There are limits to what I would discuss in the "Twitter High street" though .. If a patient Asked me to look at their ingrowing toenail I would quietly (via DM) point out this was not the best place and signpost them towards somewhere they could get help. Personal / professional boundaries are important on social media but they boil down to common sense and what you feel comfortable doing ... I know many nurses who would merely wave politely but not engage at all.

    Teresa Chinn


  10. I certainly wouldn't block a patient if they just followed me - I personally would feel that it is too hostile. They can still access your timeline and see exactly what you are tweeting. If I were ever faced with someone tweeting me about personal issues I would probably opt for a polite message signposting them away from Twitter as discussed. If it was persistent I'd then consider blocking but I wouldn't consider it routinely.

    I once had a patient email me (via my blog at the time). I ignored the email and got in touch with them through the practice mechanisms - all the communications were then in the primary care record. I saw them in the surgery and explained how I felt I couldn't respond through that method. They were fine with it.

    Otherwise I'm with Arabella - it's all very public. Live with that and act accordingly.

  11. I have declined patients' friend requests on Facebook. But Twitter's different to Facebook. As Shane outlines above, blocking on Twitter doesn't actually stop someone from being able to view your Tweets. The only way to do that is to protect your Tweets. And if you're going to padlock up, you might as well go back to Facebook.

    I also have a number of followers who are anonymous. Are they my patients? Who knows. Maybe ClaudiaX4589, who wants to have sex in the moon next summer, is my patient? (She got blocked.) It's the same issue as before really; be careful what you Tweet, or be anonymous.

  12. I am very careful on facebook, so no patients. I don't block them on twitter. I get some questions on my blog in the comments but I never answer those, sometimes I refer them to my about: "The author does not provide any medical advice in this blog, and the Information should not be so construed or used."
    I am in favor of clear boundaries, besides practicing medicine via Internet is mostly inappropriate and doesn't leave any room for the human in the patient. Thanks for raising the issue, take care,

    Dr Shock

  13. I don't think this something that any professional should even consider. The block function on Twitter is there to stop abuse and unwanted attention. If you get a number of blocks in a certain period of time an automated system kicks in and suspends your account. A cavalier attitude to blocking can end up with a very unintended consequence. Whilst no professional alone will cause this to happen they could contribute to it happening.

    If you have chosen to speak in public then patients should not be the ones that are punished for that decision. If you think that there some people that shouldn't be listening to you then you need to rethink whether Twitter is an appropriate medium for you to use.

    I would also note that those people who would respond to contacts from patients through a direct message should be aware that they need to be following the person back for it work. Whilst I strongly disagree with blocking people following them back is entering into a form of virtual "relationship" which means that they would reasonably expect conversation or dialogue.

    I like the idea suggested by Euan of contacting people who request information through formal channels, that is the most professional solution.

  14. Thanks for all the comments so far. I acknowledge that we all have different views and there are no right or wrong answers. It seems we are all agreed that practicising medicine, ie forming a doctor-patient relationship on Twitter is inappropriate.
    Many of us don't see any problem with our own patients seeing what we say on Twitter but some doctors, and others (I'm referring here to comments not just on this post but which have been made on Twitter earlier in the week), think that it is not appropriate. They are worried about the boundaries. They are trying to decide what they want their Twitter presence to be like and may choose to have a protected account as a way of minimising uncertainties. That is entirely legitimate. If I had had experiences which made me uncomfortable I would think about other options as well, I am sure.

    Just a note to Daz, you don't need to follow someone for them to be able to send you a DM. AS I said I would normally consider sending a DM to someone who I do not follow as very rude. However, in this case I am making a judgement that it would be appropriate. My message to them would only be to explain that this wasn't the proper channel to deal with the request and ask them to contact me in the practice. When Euan was emailed he decided to ignore the email but my concern is that I would want to let someone know as fast as I could that a I wasn't going to be replying. And also that their message was public. So it would only be to protect the patient that I would send them a DM. I would not follow them and allow a DM conversation to develop because I agree with you that this would not be the right thing to do.

    See, we're even getting confused here with unlimited characters, never mind 140!

    Thanks again,

  15. I'm not a doctor (I'm a social worker and have an anonymous Twitter account) but from my experience and understanding I think I agree with the post - although different issues re: different professions. My Facebook account is wholly personal - even though I don't actually use it that much. As for Twitter, I wouldn't block anyone just because I think the conversations I have and links I share wouldn't cross the line. I don't tweet about work but I do tweet about social policy/social care and social issues.
    The option for a protected account is always there but another protection, if you do have an open account as a health or social care professional is to tweet as if everyone is following - patient/parent/child/boss.
    It's another means of communication and we are very much still finding our way.

  16. My two cents. I cannot imagine trusting Facebook to be a secure or private space. Twitter, Facebook, Google Plus, etc, they all essentially place you on display in a glass fishbowl. Yes, blocking someone can be a hostile act, ignoring a person you don't know is less so. Blocking will offend some people, and that may impact on your professional practice. The reverse is also true. The best practice is, as a departmental secretary used to say in her email footer, "Live as though everything you do will eventually be known." In social media, that means only say things that you assume will be seen universally.

    There are healthcare workers I follow in social media. None of them are members of my personal healthcare team, however, that doesn't mean that can't happen or won't happen in the future. I spent a lot of effort trying to avoid having any colleagues from my research projects or church or clubs as members of my healthcare team, but darn it, I work and play with the BEST people! So my doctor sometimes introduces me to his students as a patient who is also a colleague, and explains that this is part of life in a small town. Social media makes it smaller. Any social media.

  17. I suppose one of the issues here is the etiquette used in the different Social media spaces. I wanted to simply protect vulnerable patients from misunderstanding of where the boundaries lie in that professional relationship. However it now seems that I might have inadvertantly stepped across a different boundary I was not aware of (i.e Twitter etiquette vs FB.)and this is viewed as some sort of hostil act which is as far from the truth as you can get.

    As a newbie of less than 2 weeks in that space I felt that blocking was an appropriate response as I felt that there were significant dangers in doing otherwise.

    This just shows the dangers of this social space where the rules are still ill defined. Twitter now locked for colleagues and friends alone. Nothing unprofessional but just like my personal space and boundaries!

    1. James, I know a great many professionals who do feel exactly as you have described. While some of them do use their real name and identity in social media, others protect their privacy through the assumption of a completely different name, and then avoid discussing healthcare issues of any sort in a social media space. Personally, I admit to have a bit of my own agenda. I am committed to transparency in many spaces for many reasons. Despite Google being confused here about which identity is authoring my posts, almost everywhere I am @pfanderson. Many of my colleagues disagree emphatically with this, and would be much more comfortable with the approach you are describing. A private locked account is entirely suitable for some folk, especially if they prefer to set clear boundaries, as you are describing. I also know many people who do distinguish by platform. You are in good company. :)

    2. Thanks James. I'm glad the discussion was helpful to you. I think we have covered a lot of ground in this debate and I am sure it will be useful to many in the future.

  18. That is a really good question. Although patients should respect the doctor, there is a fine line somewhere. Getting to close can be a conflict of interests. I agree with you being followed on twitter might not be so bad but Facebook is more personal. As to not insult the patient, I would probably end up ingraining the request and hope he eventually takes the hint.

  19. I'm not a doctor but I use twitter and of course it isn't like facebook platform at all. I think being as people can already see what you are tweeting anyway regardless, there's probably not a lot of point in just blocking them initially. It might be perfectly innocent, but of course if you feel the boundries are being crossed and they persistantly carry on then by all means block them so they cannot bother you.

    You will only get the odd one who won't be respectful and by which time you will have blocked them anyway. The only problem with this is : then they can still see all your personal tweets and I personally do not think twitter should allow just anybody to view your tweets unless they are on your friend list. I mean it is totally an invitation for stalkers don't you think?

    I know I am not a doctor, but if I was I should think I would be more worried about a patient going on twitter under a different name, not budding you and reading all your tweets. Don't you think that is slightly more disturbing? Don't you think that twitter should actually have a button that you can click to have total privacy? I would think that anyone should want that function on it if absolutely necessary, but it isn't on there and I wonder why nobody mentions about this at all. Not, only that, especially for someone who is a doctor etc, I mean you could be talking to someone in another clinic and they are reading all the personal details and you would be oblivous to it because they won't have budded you in the first place.

    It's one reason I stopped using twitter, because you have absolutely no privacy, now twitter is alright if you want to tell the whole world something, and you really want the whole world to know something or certain things. Yes, for that it is absolutely the business, but for personal or professional use in any privacy kind of way? No, utterly useless for that and really just an invitation for stalkers in my opinion.


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