Saturday 4 May 2013

Balancing personal and professional presence in social media.



During the week I was talking to some of the doc2doc team and they asked me what I thought about the GMC guidance on social media.

I think that the guidance is good in that it states that the use of social media can very positive and worthwhile for any doctor. I think that it is likely to increase engagement with social media for doctors, and through that provide many opportunities for learning. It doesn't provide guidance on some of the issues which I think are important, for example, what responsibilities does a doctor have before encouraging patients to engage in a social media space. We will have to wait for future iterations to deal with these scenarios.
But within the twittersphere and blogosphere the reaction has been dominated by controversy over the  statement that "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name."
I still hear people talking about the guidance being impossible to operationalise because how will the GMC identify these pseudonymous doctors? But why would they be trying to? No one would know if that person was really a doctor or not. The GMC have clearly said that the guidance does not "change the threshold for investigating concerns about a doctor's fitness to practice". This means that being anonymous/pseudonymous will never be an issue in itself. But if it was established that a doctor was for example bullying a colleague, or breaking patient confidentiality, then the fact that they were doing this without revealing their identity might be seen as being an aggravating factor.
Some people say that the guidance can't protect the public from charlatans who represent themselves as doctors when they are not. Well, in a way it does. If it is good practice to identify yourself then we can tell the public that they should not trust the authority of any one who represents themselves as a doctor, but  does not identify themselves, and then tries to give them advice.

When I tweeted the link to this interview earlier, Phil replied


Is it possible to separate medical and personal presence on Twitter? Why would you want to? Are doctors concerned that their personal interests or feelings will affect their relationships with colleagues or patients? If so then they may wish to try and separate our these different parts of their identity by setting up more than one account. But personally  I'm happy enough to tweet about going to a gig from my @amcunningham twitter account. Why would or could a tweet like the one that follows be an issue?


A few weeks ago I was asked to write a few paragraphs on how I think about how I present myself online for this ebook on "Social Media and Mental Health Practice".



How do I present myself online?

I first started using social media because I wanted to network so that I could do my job in medical education better. Yes, I am also a GP but I did not see social media as something that would help me to be a better doctor. I’m still not sure that it does, although I certainly do not think that it makes me a worse one. But I am very aware that most of what I say and do within social media is public. I want it to be that way. I do not aim what I say at my patients (or students) but I’m aware that they might read it, and I do not want them to be shocked or upset or worried by anything that they see me write. I aim to be professional, and I aim to respect professional boundaries.


When I am in the consulting room I reveal very little personal information. I doubt that patients are really interested. They walk in to see me and want and need to talk about them, not me. They often politely ask how I am. If I’m running late, I might smile and say, ‘Busy!’ But I would not share my own personal woes and worries with a patient. It would be wrong for me to burden them with my personal concerns. Of course, if they ask did I enjoy my holiday we might chat briefly about that. I don’t close down these conversations but I would never initiate talk about myself.

I share very little personal information online. I do not usually talk about my friends or family publicly online, and this is often to protect their privacy. However, this year I am sharing a photo that I take every day. In some ways this often reveals more personal information about me that what I write. It is something that I am aware of but rarely feel constrained by. I think that in many ways I am quite a private person, so this maybe more than being ‘professional’ defines how I am online.

Of course I might share some difficulties online, for example struggling to make technology work just the way I want it to! I don’t think that is a problem. It shows a different side of me and it is unlikely to impact in any way on the professional relationships which are important to me.I have thought about how I present myself online over the years. I try to be calm, collected, honest and independent. I hope that I come across as I do when I am offline. I am proud that when I meet people offline, who have first known me through social media, they often say that they feel as if they know me already. I would be unhappy if my online presence was considered inauthentic, so this pleases me.

 How do you manage the boundaries between personal and professional? What are the issues for you?

17 comments:

  1. "I first started using social media because I wanted to network so that I could do my job in medical education better."

    I guess this is the issue I'm facing, in that I'm enjoying encountering medicine based discussion etc, however I started using twitter for entirely different reasons, and as such the style I use is not one I'd think as safe for work. I know some of my followers don't enjoy some of the topics I incessantly tweet about, and I'd not want to subject them to #meded tweets, two accounts, with overlap via RT. For me it'll be the only way.

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    1. Well that makes a lot of sense! If people aren't using Twitter or blogging already I always advise them to think about what they want to achieve before starting.
      I can understand why two accounts could work for you very well.

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  2. I don't like to use twitter too much for personal interests for fear of creating too much unwanted chatter for those who are following me for my main professional interests. If I wanted to get into tweeting about religious beliefs or some obscure interest I might want to use different and possibly anonymous twitter handles - I would not be identified as a doctor in my bio but it might come out in some of the discussions as could anyone's occupation. As long as I'm not giving medical advice I don't see a problem with that. I suppose the other grey area is in the medico-political arena where someone might want to sound off against Government policies on the health service etc.. If it was a general criticism of policy as opposed to whistleblowing a specific incident/NHS employee I don't see why this can't be done under a pseudonymn. I enjoy reading the opinions/rants of angry skeptics as there is often more than a grain of truth in what they say. Yes, it is possible that a very outspoken and off the wall comment could damage the profession, but how many people in the media etc. would give credence to unattributed comments. Some of my colleagues in the US are afraid of getting sued if they use their real identities and are removing their accounts.
    I am aware that I may be putting myself at risk of litigation by being critical or disparaging about studies about drugs/devices due to the UK's ridiculous laws on libel. I'm not sure if using a pseudonym would protect someone from a libel case, but I guess they are more likely to go after someone with plenty of money!

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    1. "If I wanted to get into tweeting about religious beliefs or some obscure interest I might want to use different and possibly anonymous twitter handles - I would not be identified as a doctor in my bio but it might come out in some of the discussions as could anyone's occupation. As long as I'm not giving medical advice I don't see a problem with that."

      I cant see anyone having a problem with you doing that if you choose. It sounds sensible.

      "I suppose the other grey area is in the medico-political arena where someone might want to sound off against Government policies on the health service etc.. If it was a general criticism of policy as opposed to whistleblowing a specific incident/NHS employee I don't see why this can't be done under a pseudonymn. I enjoy reading the opinions/rants of angry skeptics as there is often more than a grain of truth in what they say. Yes, it is possible that a very outspoken and off the wall comment could damage the profession, but how many people in the media etc. would give credence to unattributed comments."

      If people want to rant about government policy under a pseudonym it is their choice. Personally I would rather than public action against policies that I am unhappy with. I'd almost say it is a moral obligation. But if people feel that they can't do that but they can still achieve something worthwhile under a pseudonym then I suppose that is the best that can be done in difficult circumstances.

      Does anyone really think that political commentary (whether under a pseudonym or not) might be dangerous to the reputation of the profession? I sincerely hope not! This is what free speech is about and I would always defend this right.

      "I am aware that I may be putting myself at risk of litigation by being critical or disparaging about studies about drugs/devices due to the UK's ridiculous laws on libel. I'm not sure if using a pseudonym would protect someone from a libel case, but I guess they are more likely to go after someone with plenty of money!"

      I'm not aware of this risk. Could you write more about it? I think we all have the right to critique research. Again, we might also have a moral obligation to make others aware of that which we think might be damaging to them.

      And as far as I know, a pseudonym is definitely not a protection against libel.

      Thanks for your comments,
      AM

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  3. Thanks for your response. I don't disagree with anything you have said. Peter Wilmshurst, a cardiologist, was recently sued by a US company for a large sum for being critical of a medical device when his research trial using it showed negative results. Apparently his defense that this was bona fide academic research didn't stop the English legal system from agreeing to hear the case. After a three year struggle the case was dropped when the company went into liquidation: http://www.guardian.co.uk/uk/2011/apr/21/us-company-suing-doctor-libel

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    1. I sat beside Peter Wilmshurst at the dinner at this year's Evidence Live conference. He's been sued more that once but I don't think that he regrets what he has done in any way. (and by the way is his mother is from Crossmaglen!)

      Have you read about the Defamation bill?http://www.senseaboutscience.org/pages/analysis-of-the-new-defamation-act.html

      Hopefully it will remove some of these fears.

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    2. Apparently the Defamation bill will not be adopted in N. Ireland! There was an interesting piece in yesterday's Sunday Times Magazine on Simon Wessely and other scientists facing death threats related to their research interest by 'activists' for a particular disease interest group. Why should legitimate online discussion of these issues be stifled because doctors have to identify themselves?

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    3. Who says that doctors HAVE to identify themselves? Not the GMC. They say it is a professional judgement. But are any of the doctors who have been involved in such cases advocating that they or other doctors would have been better to raise these issues under a pseudonym? I doubt it.

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  4. I started using Twitter because it enhances my work life and the things I'm interested in. It allows me to learn from people who share links, content and ideas. It also helps me stay up-to-date with my areas of interest more easily than ever before. I also find it good for sharing back with the social media community and for networking. Many online meetings and discussions have led to offline meetings, discussions, collaborations and projects. And because I use Twitter professionally I don't do or say or share anything I wouldn't share at a professional networking event, meeting or conference, or at work. So I don't find it difficult to manage the boundary - I'm well use to that from maintaining professionalism at work.

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    1. Yes, that's pretty much my experience- but as Roo says for others who started using social media for other reasons that they do not see as associated with their professional identity, there may be more complex issues.

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  5. I have blogged about this, so I won't repeat all I've said on my blog - see:

    http://peterenglish.blogspot.co.uk/2013/03/the-gmc-and-guidance-for-anonymous.html
    http://peterenglish.blogspot.co.uk/2013/04/my-message-to-bma-and-medical-defence.html
    http://peterenglish.blogspot.co.uk/2013/04/gmc-responds.html

    In brief, the original wording was perfectly reasonable: "If you are writing in a professional capacity, you should usually identify yourself."

    This was changed to "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name."

    I believe that there are many perfectly legitimate reasons - and not a few very good ones - why a doctor might choose to use social media pseudonymously or anonymously.

    I have asked them what their reason for changing from a perfectly reasonable form of words to an illiberal one, and what the evidence is that the change will have the desired effect; and they have ignored these questions.

    I asked why they thought that the guidance did not conflict with articles 8 and 10 of EHCR - and they simply stated that it did, without explanation; and I'm sure they are wrong.

    I have asked the BMA for a legal opinion.

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    1. But in GMC speak wasn't the 'usually' in the draft guidance superfluous? My hunch is that this is why it was removed. It didn't change the meaning at all, but just made it more consistent with other parts of GMP. Things that are should are all about professional judgement.

      There are indeed good reasons why a doctor might want to comment without revealing identity. The GMC recognise that by saying that it is a professional judgememt. Not revealing identity will never be something which brings a doctor to the attention of the GMC in itself.

      I'm not sure what the misunderstanding is about this or why you still think it is in conflict with EHCR.


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  6. Thanks Anne Marie. The problem is that Good Medical Practice has two separate definitions for the word should:

    1) it's best practice if you do this
    2) how you will put into practice the 'must' clauses

    This makes it very difficult for a lay doctor like myself to understand the boundaries. For me, the GMC should be the lawmakers, restricting their guidance to minimum professional standards. I think they should leave best practice to the royal colleges.

    The GMC guidance does seem to say that you can separate being a doctor and being a person online. But the GMC also believes you are able to never 'treat' a family or close friend. If we examine the latter example first, it all comes down to the definition of 'to treat'. If it's prescribing and performing surgical interventions on them, then that's relatively straight forward. However, is giving someone advice 'treating' them? Explaining medical terminology? How many of us have had close friends and family come to us to explain what another doctor said to them?

    This feeds into the social media debate. The GMC seems to believe we both can never switch off being a doctor (their guidance applies 24/7 - therefore if I were to preach a sermon in my church, this would still be covered by their guidance) yet we are meant to switch off being a doctor when dealing with friends and family and utilising social media. Everything I put on twitter and facebook, people read as a doctor's comments - even posts which have nothing at all to do with medicine! This is because everyone who reads them can see that I identify myself as a GP.

    I do comment on health related posts on twitter - I think it's part of my duty as a doctor to help clarify others' posts or correct the incorrect or misleading posts. Yes, that includes occasionally commenting on potential causes of symptoms. Do we have a duty of care to other people posting on twitter? We perhaps don't have a legal duty, but I think we do have an ethical duty. I wouldn't walk past someone having a heart attack in the street, so similarly I wouldn't go past an incorrect or dangerous tweet on twitter.

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  7. Thanks Phil,

    Let's go back to the 'should' definition:
    "‘You should’ is used when we are providing an explanation of how you will meet the overriding duty.
    ‘You should’ is also used where the duty or principle will not apply in all situations or circumstances, or where there are factors outside your control that affect whether or how you can follow the guidance."

    There is no 'over-riding duty' for a doctor to have a social media presence. Therefore the definition of 'you should' which applies is the second one. This means that professional judgement is needed. If a doctor decides that the best thing to do is not to reveal their identity then that is OK. To me it is as clear as that.

    The GMC stopped restricting themselves to the bare minimum with the first publication of Good Medical Practice.

    Next, let's deal with 'treating'. GMP says "wherever possible, avoid providing medical care to yourself or anyone with whom you have a close personal relationship." It is NOT an absolute ban. There is much more in paras 17-19 of the supplementary guidance on prescribing, including what to do if you do have to prescribe for yourself or someone close to you.
    Do you consider giving advice or definitions to a friend or family member as providing them with 'medical care'? I don't. I don't think that most people would.

    Again I go back to why would someone want or need to separate their personal and professional presence online? Within the platform of Twitter I am essentially always professional. I know that anyone could see it and I conduct myself accordingly. But that does not mean that I don't think I can share some of my personal life there. I'm making professional judgements about this all the time. But I am also making personal judgements that I don't want my personal life to be public which maybe dictates my behaviour more often.

    With regards to your last paragraph I whole-heartedly agree. We have to use our shared, professional 'common sense' about this. You'll be very interested in Victoria Betton's posts on this.

    Thanks as always!

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  8. I recently posted a question about the evidence base for something that my employer does. I didn't say that they were doing anything improper, simply questioned whether the evidence supported doing it. I did this using a twitter account which names me; but I have never stated on Twitter who my employer is.

    It was entirely appropriate IMO to use Twitter for this, as discussion about this is much broader than the particular employer. I relate on Twitter to followers/ees with expertise in a range of related academic disciplines from outside the body I work for. Furthermore, the body I work for is likely to say "if we do it it must be right", and cherry-pick the evidence supporting it, so I don't trust it.

    I am a consultant on the usual NHS contract - see http://www.nhsemployers.org/PayAndContracts/MedicalandDentalContracts/ConsultantsAndDentalConsultants/Pages/Consultants-KeyDocuments.aspx and in particular the section that reads:

    "A consultant shall be free, without prior consent of the employing organisation, to publish books articles, etc and to deliver any lecture or speak, whether on matters arising out of his or her NHS service or not."

    I was called in to see a director and informed that according to a recently published policy that states (wrt personal twitter accounts) "It is not appropriate to discuss [] policy on individual social media accounts, this should be discussed internally if applicable". The fact that I have never stated that I am employed by them was irrelevant because "we know you are our employee".

    This seems to me to be a perfect reason why doctors should be permitted - even encouraged - to tweet under a pseudonym.


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  9. This means that being anonymous/pseudonymous learn more will never be an issue in itself. But if it was established that a doctor was for example bullying a colleague, or breaking patient confidentiality,

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