Patient Confidentiality and Social Media

In the last decade, social media has changed the face of medicine. There are physicians who live their lives on social media and update their social media status q4h.  In the midst of a physician’s personal photographs, we often come across a patient’s clinical encounter with detailed description, ECG/Radiology Imaging displaying the name of the patient. We need to remember that any information posted on social media could end up on the front page of a newspaper. Posting patient photographs, meticulous description of hospital encounters can certainly put us at risk of litigation.

Breach of patient confidentiality on social media is a legitimate concern and as Health Care Professionals, it is our responsibility to ensure patient privacy. These issues can be extremely sensitive as patients share vital bits of information with physicians (sexual, psych, recreational drug use etc.). Violations in these regards expose us to liability under various privacy laws. 

On one hand, the western countries are extremely cautious about "patient confidentiality" issues whereas in developing nations, the concept of patient confidentiality remains unknown to many medical students, residents, practitioners and as well as the patients. It is not uncommon in third-world countries to find residents and even physicians openly discussing patient details, prognostication in elevators and hospital cafeterias. Conversely, personal information is not released to a patient's spouse without prior patient consent. 

Social media potentially improves health outcomes, facilitates developing a professional network, increases personal awareness of news and discoveries and also aids in providing health information to the community. And the intent behind information sharing on social media is knowledge dissemination and having discussion for the overall betterment of patient care. Nevertheless, this should not be done at the cost of breaching patient confidentiality. Here are a few suggestions that can provide a useful framework before posting any patient related information on Social Media:

• Avoid writing about specific patients: It is reasonable to generalize things when discussing about a patient rather then referring to someone in particular. This shields identification to some extent without loosing the point of discussion.
• Obtain patient consent when required: If you are going to post a photograph on a social media platform such as patient’s ECG or Radiological imaging, make sure you crop the image or take explicit patient consent before posting such information online. If done in the right manner, it is rare to find a patient who will refuse to share his details.
• De-identification: De-identification is the process used to prevent a person’s identity from being connected with information. Common strategies for de-identification include deleting or masking name and DOB, Age, ZIP code. Adding hypothetical points to a patient’s story is another way to de-identify but without loosing the crux of the matter. The Health Insurance Portability and Accountability Act defines data as de-identified if it “does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual is not individually identifiable health information.”
• Use a respectful tone when discussing patients: Social Media is accessible by everyone. Many patients do not appreciate the fact that majority of medical decisions are based on a physician's past experiences, opinions, local practices and comfort level rather than mandated rigid protocols. Beware of this whenever you are involved in an online discussion accessible by patients  Also, be courteous and demonstrate utmost respect towards a patient. Even when the outcome is going to be dismal, be sensitive while expressing your opinion.
• Have a separate personal and professional account
• Know your local/national laws and policies: If you medical licensing body or hospital has a social media policy, then give it a thorough read. 

Further Reading:

Ventola CL. Social media and health care professionals: benefits, risks, and best practices. Pharmacy and Therapeutics. 2014 Jul;39(7):491.

Patients, Physicians and Google - What are we up to?

In this era of technology, all of us have dealt with patients who first "google" their symptoms, try and figure out what is possibly happening with them, reach a self diagnosis and try some remedies to see if their symptoms get better. And if things don't settle down, then they visit a physician. From whatever I have observed so far, most physicians tend to get upset with these patients (some physicians call them semi-literate patients or an e-patient) but only a handful of them actually try and talk to them, dig deep and understand their concerns, do shared decision making and reach a treatment plan that is acceptable to both, the physician as well as the patient. 
It is not uncommon to come across this demanding subgroup of patients in the ED but in the outpatient setting where there are no time constraints, every other patient is an e-patient. Let us understand why do patients do this:

Why ask google when physicians are available? 

In a physician - patient relationship, historically the physicians have dominated the conversation (ideally it should be the other way around) and patients have always been submissive. But things are changing and many find it hard to accept when a patient questions on a diagnosis or treatment plan. Also in modern day scenario, I think the key issue that we are dealing with is lack of trust on physicians . If we look back at the last decade, the way media and television has projected physicians, things have really gone away too far and it has changed a lot. Now, patients do not see physicians as someone they can readily rely on, so they want some baseline information to start with. And when they visit a doctor, their chief concern is that they do not want to be mislead with unwanted investigations and sometimes unnecessary medications. What remains the best way to get unbiased help is the always available "GOOGLE". 

And this may not be the only reason for googling symptoms, people have also become more aware and they want to know what is happening with them and much more about the medications, side effects. Fortunately (for some physicians), this wave of technology has spread only to the metropolitans and a majority of patients in India are still clingy and depend completely on doctors to make decisions for them.

How do physicians react when they deal with an e-patient?

All of us would agree on this that doctors have big egos and as physicians do get offended thinking that they are confusing our medical degree with google or we might think that 

How can he come with a self-diagnosis? 

Then why the hell did I go to medical school?

Due to this passive aggression, poor rapport and cold relationship these patients get shunted among various specialists (which is bad medicine) consuming time and wasting resources.

We as health care providers, need to understand that medicine is much more than just making the correct diagnosis and treatment. Empathising and emotional support to a patient often can do wonders to patient's compliance and symptom relief. Social media, technology and google cannot give them the healing touch, but you can. It just needs some patience and a few extra minutes.

What can we possibly do about e-patients?

Short answer: Shed your ego and do shared decision making

If a patient is enlisting his/her symptoms and also what they read about it on internet, be upfront and ask them what do they think is happening with them and be willing to listen to their self-diagnosis (which might be the correct diagnosis!). Listen to them carefully without the prejudice that they are wrong. Ask them where did they read about it and what do you think about what they have read. Also give them some more reliable resources to refer to a t then end of your consultation.

Most of them don't want to offend you and neither they are testing your knowledge but they are just concerned about their health and want to participate in understanding their illness, more importantly they want to have a feeling of security and reassurance that they are not being mislead. Unfortunately this is what we have come down to. Our job is still to help them out, take a few minutes and do shared decision making. These e-patients are only going to increase in future, so rather than creating being insecure and making a hue and cry about this, we need to accept this and be amazed if they are not googling their symptoms!

Googling symptoms is absolutely normal.

And guess what do physicians do when they want information on something?

Google

What if you have no idea about what they are talking about?

If you have no clue about a treatment that they are referring to, before you tell them that it makes no sense. Check on that and don't be surprised if they tell you something about medicine that you don't already know. (Something like non-surgical treatment for appendicitis). Medicine is making advancements everyday and it is hard to stay up to date. So hold on, tell them that you have not heard of something like this but you will find out more on this and revert back. Many times, patients with chronic diseases know more about their disease and treatment than an emergency physician!

I think sooner or later we are going to have a computer that can give a reliable list of differentials. We already have systems in place that alert us about various drug reactions, doses etc. then why not a list of possible differentials. But again, medicine is not about only the diagnosis and treatment. A physician has much more to offer..

Bottom Line:

• Shed your egos and just listen to them.
• Look at e-patients as a possible help. Most of them are just concerned and want to make sure they are on the right track. 
• Set the right rapport and build that trust to drive things smooth.