Physicians on Facebook

There’s a short piece in the latest JME about the use of social networking sites by medics that’s got me thinking.  In it, Guseh, Brendel and Brendel suggest that physicians need to be especially careful about accepting, say, a Facebook friend request from patients because of the nature of social networking sites and the possibility that normal privacy rules may be violated.  (For the rest of this post, I’ll talk mainly about Facebook, but that’s just for convenience.  The points will stand in relation to any social networking site.)

I can see something of the motivation for the worry here, but I’m not sure I share it.  The reason for this is that I have yet to be convinced that the online world presents us with any new problems: all it does is re-manifest old ones.  For that reason, there’s nothing about which we need to get all that excited.  Nor is there anything special about physicians, as opposed to anyone else, on FB.

Let’s start with the first area of dispute: is there anything special about online social networking?  The paper hints that there might be.  For example,

if a psychiatrist were to become an online friend with a patient and discuss aspects of the treatment on the website, other online friends could learn potentially compromising information about the patient.

This is probably true – but I wonder whether there’s anything special about online communities here.  Facebook is like a bus.  Its users know that what you wouldn’t say on a bus, you shouldn’t say online; if a psychiatrist were to meet a patient on the top deck and start talking about treatment, other people in earshot could learn something compromising.  This is a fairly trivial point, though.  If an HCP of any stripe needed this pointing out, I’d worry that he was missing something important anyway.

Of course, the net gives us the capacity actively to search for information in a way that we couldn’t otherwise.  But Smith searching for Jones or information about him online is really no different from following him home, sweet-talking his friends, or rummaging through his bins.  Finally, using facts that one may accidentally learn online in the context of a consultation doesn’t seem to be so different, morally, from using facts that one may accidentally learn in any other situation; and carelessly propagating information online isn’t, by the same token, all that different from carelessly propagating it anywhere else.

Nor are the boundaries of propriety in relationships all that different online; all the problems that one might cite here are problems that one might equally well cite in relation to offline social interactions.  For example, a doctor who tried to “friend” a patient online would perhaps have violated some kind of expectation about behaviour – but the same applies to a doctor who gets too chummy with a patient whom he happens to see at a pub; we’d expect doctors, like anyone else, to follow certain rules of (for want of a better word) decorum.  And the same applies to patients: a patient who tries to friend a doctor, or who is chummy in the pub, is a bit odd, too.  (Transference and countertransference, anyone?)  So there’s nothing special about Facebook or other social networking sites there.  On the other hand, a doctor might form a friendship with a patient or ex-patient in the normal course of affairs: there’s nothing to say that a medic and his patients have to maintain glacial relations if the situation naturally could sustain something else (for example, if they happened both to go to the same social functions or have mutual friends); and, again, the same applies online.

Social networking, at least in this respect, isn’t all that interesting.

Move now to the second area of dispute: the claim implicit in the paper that there’s something particularly noteworthy about physicians.  There’s a hint of what one might call “medical exceptionalism” in the paper, and it generates the recommendation of restraint in the use of sites like FB:

[P]hysicians might choose to become Facebook users but populate their site only with professional information, such as area of speciality, office address, academic affiliation and contact information.

But – and this was tacit in the last couple of paragraphs – it’s not entirely clear why this might be: why, that is, physicians have, or ought to have, special rules that don’t apply to anyone else.  Of course, a person may choose to place all kinds of limits on what they do or don’t say online, but there’s nothing special about physicians here, and it’s not self-evident that any of this amounts to an obligation.  We wouldn’t, I don’t think, expect bank managers or teachers to take special precautions beyond what we’d expect of anyone else, so I’m not sure why doctors are different.

This isn’t to deny that your role might influence what you do online.  For example, I think my own FB page is public, but although I’ve accepted FB friend requests from students and ex-students, they have been (in the main) only from people whom I’ve taught face-to-face.  I purged my distance learning students because it occurred to me that, never having met me, they might not quite appreciate some of the banter between me and my friends; I’m more confident that campus-based students’ll know how I tick: we have, after all, know each other a while and been out for a curry on occasion.  (Sorry about that Peter and Robert: I’m sure you’re lovely people, but I just don’t know you well enough.)  But this has to do with fairly workaday concerns about managing my public profile; it’s not that I think I have any obligations in particular – not in any strong sense, at any rate.  I don’t think that I have any responsibility to tone things down because of my job; nor do I think anyone else does – I’m just aware that some of the jokes I and my friends enjoy are a bit near the knuckle at times, and could be misconstrued.  Thus I’m not going to have them clog up the news feeds of people whom I’m not sure will get them.

So as well as social networking being none-too-interesting, I think the same applies to medics; what we can say about them, we can say about anyone.

There’re other considerations as well.

Guseh et al point to the privacy aspect of social networking, but I think that what they don’t question – and what is worthy of question – is what “privacy” actually means in the context of online social networking.  There’s a steady stream of examples of people saying waaaay too much on their Facebook page – this is a quite marvellous example – but, again, I don’t really see how privacy has to be seen as being all that big a deal.  If you don’t want to have something accessible, don’t put it online: pace the example in the link, most people get that, and, again, it’s really no different from offline prudence.  At the other end, it’s probably a bit off to go trawling for information – just as it’s a bit off actively to keep tabs on someone offline.  Again, so far, social networking doesn’t obviously offer anything new to cause us to worry.

On the other hand – and I’m speculating wildly here – it might be that the evolution of electronic social networking is of philosophical and ethological interest.  One might wonder, for example, whether the age of mass and electronic media is one in which “privacy” means what it used to.  It’s possible that Facebook does undermine traditional boundaries – but it’s also possible that it’s only a success because of the fact that people are willing to publicise themselves in a way that either they wouldn’t, or couldn’t, a generation ago.  (Here’s one for the counterfactual historians: had Facebook and webcams existed 50 or a hundred years ago, would they have been as popular as they are now?  I kinda suspect that they would.  Moralise all you like, but some people are self-publicists, and some people like watching ’em.)  Call it a Debordian “spectacular society” if you want, or a general pervasive vulgarisation, or – and this is my preferred option – shrug and note that something interesting might be happening but equally well might not.

The point would stand, though: if “privacy” has mutated, then proposing guidelines to protect it on the old lines mightn’t be much more than a thumb in the dike.  And it’s equally true that most people are pretty savvy about privacy and have adapted perfectly happily to the online world.  The context of privacy has perhaps changed: but I suspect that that’s all

The most we can say is that it might be prudent to keep certain things offline just in case someone does something with that information that we would prefer them not to – but, by this token, we should be more careful about what we put in the bin just in case someone chooses to rifle through it, notwithstanding that in this case it’s the bin-rifler who’s causing the problem.  As long as we’re not gratuitously silly in the things we put online – the equivalent of putting a box clearly labelled “my bank and medical records” in a public bin, we shouldn’t have to worry.  The point is that professionalism has nothing to do with it.


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