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Moving to the south is an eye-opening experience.  First, there's the friendliness of everyone; I remember the first time a stranger talked to me in the grocery store, it made me nervous.  In Philadelphia, where I went to med school, anyone talking to you in the grocery store was either hitting on you or crazy.  Add to that list: "or from the south."

Then there's the politeness factor.  Kids are expected to say "yes sir" and "yes ma'am" when answering questions asked by adults.  Most northern-bred transplants to the south that I've talked to think this is a good thing - a refreshing change from the rudeness you often get from kids.

But perhaps the most foreign thing in coming to the south is something called "Social."  Yes, the picture above is from their website.  Social is a manners school where kids are not only taught how to eat right at the dinner table, but also how to address members of the opposite sex and to perform various dances with a partner.  The formal training happens around 6th grade, but the talk of who will get partnered with whom is fodder for many parental discussions for several years leading up to the actual course.  Parents arrange partnerships between their children - kind of like arranged marriages.  My two oldest kids participated in Social (which is run by a local family), and gave it mixed reviews.  We didn't force it (although we did get calls regarding our kids' availability), and one of them liked it enough to do it three years, while another barely tolerated one.

All of this came to mind because of a phone call I got this morning requesting an interview about social media and the medical field.  How are doctors handling blogs, Twitter, and Facebook?  What are the guidelines I abide by, and should the professional societies (AMA, ACP, etc)  be involved it directing their members on how to use social media?  The interview was particularly timely because I was working on a post that quoted some funny patient/doctor interactions, but was having second-thoughts due to confidentiality concerns.  How do I quote patient interactions without making it sound like I'm making fun of them?

So, I thought it would be fitting to write my "Ten Commandments of using social media."  They aren't really commandments, but I like to feel like Charlton Heston every once in a while.

1. HIPAA is the final say. HIPAA has privacy statutes that set clear boundaries of what can and cannot be said about individual patients.  The bottom line is that the only way we can reveal information about patients to others is by their consent.   Social media has a lot of pitfalls in this area, including: doctors blogging about individual patients and direct communication over Twitter and Facebook about doctor/patient matters.  Breaking this rule is not just an ethical violation, it is a legal one.

2.  Obey the "elevator rule."  In medical school we were taught the "elevator rule," which states that you should never talk about patients in the elevator when there is anyone else present.  You must assume you will be overheard.  In the same way, social media is about communicating with a large number of people and so should be used with the same assumption.  Don't write anything you wouldn't want your patients to read.

3.  Think before using social media. The lines of what can and cannot be written using social media become gray quite quickly.  Is it OK to talk about people you saw today, or should you wait a few weeks?  What facts do you need to change to make identifying the patient impossible?  What do you want your patients to know about you?  All of this springs from your overall philosophy of using social media.  My blogging is driven by a desire to show doctors to be regular humans, so that is what I write about.  Facebook, on the other hand, is for me to connect with friends (except on my Fan Page, where I interact with readers).

4.  Don't friend your patients on Facebook. This springs out of rule 3, as there are things patients don't need to know about me that I want my friends to know.  I want to be able to show vulnerability and frustration.  I am Rob, not Dr. Rob or Dr. Lamberts on Facebook, and I want it to stay that way.  Too many lines can be crossed when friending patients, so I don't do it.

5.  Beware of Twitter.  Unlike Facebook, Twitter is not a walled-garden.  People can follow you without your permission.  Twitter is a truly public forum that should be seen that way.  The elevator rule definitely applies in Twitter.  I think of Twitter as advertising; we are putting ourselves out there for all to see, letting them decide how worthy we are to be followed or responded to.  The public nature of the forum can be engaging, as can the banter between friends.  But there is a great temptation to post Tweets about frustrating patients after walking out of the exam room, or exposing too much of your feelings for the world to see.

6.  The Internet is Forever.  What I write about using social media is recorded for posterity.  There is no way to take back what you sent over your RSS feed.  Unlike spoken words, which are (usually) gone after the airwaves stop vibrating, everything is recorded on the Internet.  You may not bear the consequences of your writing for years, but it is there to be found once you have written it.

7.  Anonymity is dangerous. I understand why some bloggers choose to remain anonymous, as their workplaces my not understand or appreciate what they do while online.  Yet many anonymous bloggers lose the ethical boundaries holding other bloggers in check.  Anonymous bloggers are much more likely to talk about actual patients, assuming they will never know it's them and can't find out.  Early in my blogging career, a blogger who went by the name "Flea" was exposed in court during a malpractice trial.  He had to settle the case.  Anonymity is a very thin shield and invites abuse.

8. Don't do it for ego. When I started blogging 4 1/2 years ago, I was a nobody.  Pretty soon, however, people started reading my blog and actually liked my writing! This is a big boost to the ego, as is the follower count on Twitter or fans on Facebook.  After struggling with the addictive nature of this ego boost, I went back to my core reason for blogging: showing people doctors are ordinary people.  I go back to that core reason whenever I am led astray by a moment of fame, or a particularly hurtful comment.  This is the only way I could keep doing this for so long.

9. Enjoy the community. Social media is not a contest.  Strive only to be who you are, and enjoy all of the other good writers in the medical blog world.  Some of the best friendships I've made over the past 4 years have been through social media.  I learn much from what they write, and really appreciate their different perspective.  This is not "king of the mountain."  The strength of the blogosphere is its diversity.  Besides, there are some really nice folks out there who write  very well.

10. Share. I have never worried too much about people quoting my content or even republishing it.  Once you put something out there, it is infinitely copiable.  As long as people say who wrote it and don't take credit, they can use it all they want.  My biggest asset is not my blog or what I've written in the past; my biggest asset is my ability to write and express myself.  Nobody can ever steal that from me.  I find it a compliment when people include my stuff in their blogs, it means I am giving something worthwhile to the world.

Kind of like Charlton Heston.

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