Anonymity and Professionalism on Twitter: Room to Educate

A well-established medical blogger Dr. Bryan Vartabedian (aka @Doctor_V, a fellow gastroenterologist whom I recently had the pleasure of meeting at DDW 2011 #DDW11) seemed to ignite a firestorm this week amongst #hcsm tweeps with his post about a specific incident he saw on Twitter.  He was (is) of the opinion that:

  1. Physicians who maintain a professional presence in the Social Media space (Twitter, Facebook, blogosphere), should not do so anonymously.
  2. Professionalism and respect for patients should be maintained in this space in a manner similar to the non-internet space.

I read the blog and was sure that most people would be of the same opinion.  With only a few exceptions, most of the doctors I have encountered on Twitter have maintained a professional attitude, with a few notable exceptions, as documented in a recent JAMA Letter to the Editor.  I was definitely not expecting the eruption of sentiment from several others.

What transpired felt like a political debate between conservatives and liberals.  As a moderate I found it intriguing to listen to both sides and take it in, like an argument between the Dems and GOP on the appropriate way to decrease the deficit.  Let’s at least agree that those who have differing opinions are not going to agree, and neither side is truly “correct” or “incorrect”.

To explain the basic themes of those that espouse the opposite view of Dr. Vartabedian:

  1. Physicians do not have a responsibility to maintain an online “level of professionalism” that reflects our profession.
  2. This space is a social, not a professional, space.
  3. Physicians have every right to be anonymous.
  4. Our freedom of expression, even as physicians, is protected, and one person should not be the sole arbiter of morality.
  5. Public condemnation of individual physicians may be just as unprofessional as the actions being condemned.
  6. Since there were no actual HIPAA violations, there was no direct harm.

I am going to limit the remainder of this discussion to Point #1, professionalism. Do we have a responsibility to maintain a certain level of decorum in every aspect of our lives, or just certain aspects?  If just certain aspects, in which ones are we permitted to let loose? Is the Social Media space the appropriate place to drop our guard?

This is a matter of fervent discussion among medical educators and ethicists.  In a recent article in the Annals of Internal Medicine, Drs. Mostaghimi and Crotty said “social networks may be considered the new millenium’s elevator”.  We all know of doctors that do not keep quiet in the elevator no matter how often they are reminded of the issue of patient privacy.  The same can be said for online personae.

I have recently become more interested in the issue of medical professionalism after attending talks at the recent GI Training Directors workshop as well as a seminar series led by Drs. Sylvia and Richard Cruess from McMaster, who are leaders in this area.  They stressed that there is a gradient of professionalism and a learning curve that occurs over the years of education, training, and practice.

Two attributes of professional behavior are are germane to the discussion at hand: Morality/Ethical behavior, and Responsibility to Profession.  The fact that the internet and social media are new does not excuse the behavior, which was clearly less moral or ethical than optimal, nor does the novelty of the space eliminate the Responsibility to Profession that all who are physicians should maintain.  But just like there are some physicians whose medical knowledge, patient care, or interpersonal communication skills are less than optimal, we must realize that there are some doctors whose professionalism is so as well.

For those of us who enjoy educating, it behooves us to try to engender excellence among all of our colleagues.  We have a long way to go, but let’s keep working at it.

As a post-script, I applaud @mommy_doctor for reflecting on her actions that led to the post, as noted by her tweets that came out subsequent to Bryan’s blog (“will think about my response”; “First of all, I did cross the line with a tweet or two so I apologize”).  Such personal reflection is just as important as the discussion on #hcsm chat on Tuesday night and has continued through Wednesday.


About Ryan Madanick, MD

I am a gastroenterologist who specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD. I can be followed on Twitter: @RyanMadanickMD (he/him)
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8 Responses to Anonymity and Professionalism on Twitter: Room to Educate

  1. Jane says:

    Some who have come out against one of the main players in this scenario have done so not because of the issue, but because of him. The same harsh, aggressive, confrontational, mean personal attacks I saw him launch during this debacle were, at some points, word-for-word what he did to someone I know several months ago, both in the public stream and by DM. I also know of at least one other who has endured abuse from this man – and all three of these people happen to be women. Given that the rantings and extreme contempt for patients displayed by the likes of Burbdoc were not the subject of this individual’s tirade, my gut tells me that the fact that all of these people shouldering this abuse are women is no fluke. I have strong feelings about the tweets that precipitated this debate, but I have stronger feelings about how they were handled, and by whom. No one person is judge and jury of internet discourse. No one person is right about everything. To think otherwise would be to delude oneself.

  2. Pingback: Twitter, Doctors and Professionalism | The Blog That Ate Manhattan

  3. Danielle says:

    I’m with you – I feel like a moderate in the middle of a liberal vs. conservative screaming match.

    Obviously, there will be variations in levels of professionalism amongst doctors and also varying definitions of just what professionalism encompasses – however, after reading the posts and tweets and comments surrounding this I just can’t help but remember a dr. telling our clinical class that the way to handle professionalism complaints in the hospital was to address them privately or contact a supervisor.

    Purely in terms of professionalism I dont think Dr. V has chosen the most professional way to go about approaching this. But, that is relatively minor when compared to the sensitive nature of patient information that was potentially compromised.

    It’s just been blown out of proportion. All of it. It’s insane.

    This is actually one of the reasons I have chosen to blog and tweet with my real name, though. I think anonymously blogging allows you to do and say things you would otherwise not do or say. By attaching your name to things you are constantly held accountable for your actions by your own image.

    And, as we all know thanks to the famous Flea incident, youre never truly anonymous, so you might as well be proud of everything your name is or could be attached to.

    • Thanks for the comments Danielle.

      The rules/guidelines of online behavior for medical professionals are evolving. You are in a great period of your career. Enjoy what you are learning. Not just the medical knowledge and patient care but also the other “soft” aspects of doctoring (communication, professionalism, etc).

  4. This is a good post, Ryan.

    Like you, I have been reading the comments and trying to understand both sides. Hopefully, people will become less reactionary and learn from this issue that has been “blown out of proportion.” Sometimes an issue that inadvertently gets magnified actually brings out all the details that need to be examined. Some of the best discussions I have had have been of a similar nature – where initially there are strong reactions and opinions. But the benefit of such interactions only comes when people learn from each other and the experience. I certainly see more sides of the issue now. I hope others do, too.

    I agree with Danielle above when she says that there is a choice to blog anonymously or not, but that there is more consideration for what you say and write when you come out of anonymity. I try to write things that I wouldn’t be afraid to say in front of a crowd of nonhealthcare providers or physically sign my name to. Maybe that makes me less funny or entertaining online, but it also wouldn’t jeopardize my career or reputation. Reputations can be tarnished in a second of acting before you think. Social media and the internet enables and expedites that process.

    As you mention, I have also come across comments by others that suggest that there are new rules of professionalism and ethics with the advent of our new mediums of communications. I agree with you that our professionalism and ethics should not be compromised by various types of media.

  5. I am sure I was flagged as unprofessional in that JAMA letter about Twitter because I swear. I don’t swear in front of patients, but I sure swear on my own time. I don’t think swearing is unethical and if patient care isn’t involved, then it isn’t unprofessional.

    I have never ever once tweeted about a patient, not even with changing diagnosis etc. I speak about medical care in generalizations. Protecting privacy is paramount. That is an easy line to see.

    But who decides what’s unprofessional?

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