Blogs and Tweets, Texting and Friending. Social Media and Online Professionalism in Health Care

175 Pages·2014·1.815 MB·English

by  Sandra DeJong (Auth.)

Blogs and Tweets,
Texting and Friending
Blogs and Tweets,
Texting and Friending
Social Media and Online
Professionalism in Health Care
Sandra M. DeJong, MD
Harvard Medical School
and
Cambridge Health Alliance
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For my family, whose love and support make
so much more possible.
Acknowledgments
As a doctor, I learn from my patients; as an educator, I learn from
my students. I am grateful to the former and current child psych­
iatry fellows at Cambridge Health Alliance for bringing the impor­
tance of this topic to my attention and urging me to teach about it.
Thanks to Cambridge Health Alliance for supporting me as a Fellow
at the Harvard Macy Institute’s Program for Educators in the Health
Professions and to my Macy teachers and colleagues; without them,
this work may never have gotten underway. Finally, I want to acknow­
ledge my indebtedness to members of the Taskforce on Professionalism
and the Internet of the American Academy of Directors of Psychiatry
Residency Training: Joan Anzia, MD, Sheldon Benjamin, MD, Bob
Boland, MD, Nadyah John, MD, Jim Lomax, MD, and Anthony
Rostain, MD. The work we did together in developing our Curriculum
on Professionalism and the Internet for psychiatry is very evident in
this book; I am grateful for their wisdom. In particular, I want to thank
Dr. Benjamin, my former training director, who appointed me chair of
the taskforce. As a teacher and mentor, he has a wonderful quality of
believing in his students more than they do in themselves.
LEGAL DISCLAIMER
Care has been taken to confirm the accuracy of the information pre­
sented and to describe emerging accepted standards. However, the
author, editors, and publisher are not responsible for errors or omis­
sions or for any consequences from application of the information in
this book and make no warranty, expressed or implied, with respect
to the currency, completeness, or accuracy of the contents of this
publication. Application of the information in a particular situation
remains the professional responsibility of the practitioner.
ix
Introduction
A few years ago a child psychiatry fellow put in my mailbox a news-
paper clipping with a Post-It note on it reading, “We should be talking
more about this.” The clipping was a column by Richard Friedman,
MD, entitled “Take two Prozac and e-mail me in the morning”
(New York Times, July 16, 2008). The column started me thinking
about all the ways in which the digital revolution has transformed
health care. In particular, I became aware of how the pillars of pro-
fessionalism – boundaries, confidentiality, privacy – were being trans-
formed by technology. I started participating in national workshops
with psychiatrists and psychiatric trainees. The scope of the problem
as I perceived it grew by leaps and bounds.
In 2010, a taskforce of psychiatric training directors in the United
States was charged with developing a vignette-based curriculum
on this topic. The demand was enormous and the response positive.
When I was asked if I wanted to write a book on the topic, the need
seemed clear.
But some caveats are in order: I am a medical educator, not a
“techie.” I am also a psychiatrist, not a nurse or a surgeon or a phys-
ical therapist. Finally, I am human, and do not have a crystal ball to
see what the future may hold in terms of social media, online search-
ing, and digital technology in health care. What follows, then, is my
effort to focus on broad-based concepts of the importance of profes-
sionalism in medicine and the ways in which professionalism is at risk
in the face of the scope, speed, and permanence of digital technology.
I have tried to provide some context to these concepts and illustrate
them with clinical vignettes. Finally, I have tried to provide both gen-
eral and specific recommendations to guide health-care professionals
in clinical practice as we all walk this uncharted terrain together.
I apologize in advance to those who do know a lot about technol-
ogy for wherever my ignorance is in evidence. Similarly, I ask health-
care professionals from other disciplines and specialties to take my
vignettes with a grain of salt; they are used to make a teaching point
about technology, not to reflect the reality of clinical care.
The panoply of new technological devices and innovations is
more than can be fully covered in this book. Two emerging areas
not included are Skype and other video-chat technologies and elec-
tronic medical records (EMRs). The former largely falls under the
rubric of telemedicine and is subject to its regulations and licensing
xi
xii Introduction
requirements. EMRs raise complicated issues for health-care facilities
but largely do not involve interaction with the public except through
protected portals. For these reasons, neither is addressed here.
Technology like social media and the Internet brings extraordinary
opportunity to health care. How that technology is used is, at least
partly, in our hands. My hope is to re-assert the professional frame in
which we work and to guard the trust that our patients put in us as
individual practitioners, in our hospitals and institutions, and in our
profession.
Chapter | One
What is
Professionalism?
The practice of medicine is an art, not a trade; a calling, not a business;
a calling in which your heart will be exercised equally with your head.
Osler, 1932, p. 3681
Professionalism, to paraphrase Shakespeare’s Hamlet, is often noted
more in the breach than in the observance. When trainees in health-care
professions are asked to define professionalism, they tend to describe
examples of lack of professionalism: clinicians who mistreat patients
or colleagues, who put their own needs ahead of the team or the
patient, who lack competence but refuse to acknowledge their limita-
tions, and whose approach to clinical care lacks the compassion and
empathy that Osler so eloquently described when he called medicine “a
calling in which your heart will be exercised equally with your head”
(DeJong, 2010–12). Sometimes these deficits are glaringly obvious,
such as the surgeon who left the operating room to go to cash a pay-
check, leaving the patient on the table (Swidey, 2004). Other times they
are more implicit, only inferable by overly casual dress, sloppy docu-
mentation, poor time management, inappropriate tone of voice.
How professionalism is manifested and perceived may vary by
developmental stage, gender, and geographic, ethnic and institutional
cultures. Some evidence suggests that women value professionalism
more than men (Roberts, Warner, Hammond, Geppert & Heinrich,
2005). Some studies suggest that views of professionalism shift
over the developmental trajectory of practitioners’ careers in health
care (Nath, Schmidt & Gunel, 2006; Wagner, Hendrich, Moseley &
Hudson, 2007). What is considered professional in one health-care
1 I am indebted to Dr. Elizabeth A. Rider, who reminded me of this quotation and
whose chapter “Professionalism” in Rider, Nawotniak & Smith (2007) guided
my thinking about this topic.
1
S. deJong: Blogs and Tweets, Texting and Friending.
DOI: http://dx.doi.org/10.1016/B978-0-12-408128-4.00001-1
© 22001144 S. DeJong. Published by Elsevier Inc. All rights reserved.
2 What is Professionalism?
environment may not be in another: Jeans, open-toed shoes, and low-
cut blouses may be acceptable at some institutions in some parts of the
world, and within some specialties, but not in others. And culture can
change over time: While scrubs used to be prohibited outside the hospi-
tal in the United States, they have now become commonplace.
But professional presentation and etiquette are not a substitute for
fundamental professional attributes; the latter go deeper to the level of
moral judgment, ethics, integrity, and altruism, to what Hafferty has
called “the professional self”:
Taking on the identity of a true medical professional…
involves a number of value orientations, including a general
commitment not only to learning and excellent of skills but
also to behavior and practice that are authentically caring…
There is a meaningful (and measurable) difference between
being a professional and acting professionally.
Hafferty, 2006, p. 2152
The relationship between patient and health-care professional car-
ries a “fiduciary duty”: The professional has an obligation to act for
the patient’s benefit and the patient places ultimate faith in the abil-
ities and good intentions of the professional. Professionalism is the
foundation for the trust patients place in their caregivers. When that
trust is broken, patients rightfully protest: Breaches of professional-
ism are a common cause for patient complaints and for negative media
reports about health-care professionals (Hickson et al., 2002). In one
retrospective study, physicians who were disciplined by state licens-
ing boards were three times more likely to have shown unprofessional
behavior in medical school than were those with no such disciplinary
actions (Papadakis et al., 2005).
Health care has come under closer scrutiny in recent years as pro-
fessionalism has been challenged by changes in health-care delivery,
growing expectations by the public, the increasing role of corporate
entities, and technology. The American Board of Internal Medicine
(ABIM) began its Project Humanism in the 1980s and its Project
Professionalism in the 1990s. Guidelines for medical schools and
certification standards require demonstrated professionalism at the
undergraduate and graduate level (Association of American Medical
Colleges, Institute for International Medical Education, American
Council for Graduate Medical Education; see Rider, 2007, p. 189).
Given these requirements, efforts have been underway to try to define
and assess professionalism.
In the United States, the definition of professionalism has focused
more on the attributes of clinicians and their capacity to self-monitor,
self-reflect, and self-regulate. Qualities such as compassion, compe-
tence, integrity, consistency, commitment, altruism, leadership, and
What is Professionalism? 3
insight come to mind (Rider, 2007). In this model, professional clin-
icians are those who are constantly assessing their clinical and tech-
nical skills and trying to improve; taking care of patients from the
standpoint of values of humanism and empathy; shunning self-interest
to focus on the care of others.
Closely related, but with a somewhat different emphasis, is the
“patient-centered” professionalism model (Irvine, 2005). Writing in
the UK, Irvine emphasizes the expertise of the clinician (knowledge
base and skill set); the adherence to ethical virtues of beneficence,
nonmaleficence, autonomy, and justice; and the service to the patient.
This model reinforces the importance of developing a patient-centered
health-care culture, and of a regulatory system to assess and monitor
clinicians’ expertise, since patients themselves are unable to do so.
Implicit in this model is the notion that health-care providers should
be truthful and open with their patients, and maintain patient confiden-
tiality; they should provide patients with information so that they can
make informed decisions with their providers about their care; they
should acknowledge their own limitations of professional competence;
and they should be respectful and unbiased towards the patient’s indi-
vidual and cultural values.
As Irvine’s model makes clear, professionalism is often closely
associated with ethics, which are typically delineated in professional
codes such as the American Medical Association’s code of ethics
(http://bit.ly/kaaxBG). American psychiatrists Glen Gabbard and Laura
Roberts have pointed out that “professionalism is embodied in ethical
action” (Gabbard et al., 2012, p. 17). They emphasize the key role of
biomedical ethics concepts in professional behavior (Table 1.1).
In 2002, ABIM, the American College of Physicians-American
Society of Internal Medicine (ACP-ASIM), and the European
Federation of Internal Medicine jointly published a document entitled,
“Medical professionalism in the new millennium: A physician charter.”
The charter, based in part on the work of physicians Sylvia and Richard
Cruess at McGill University in Canada, takes professionalism one step
further to encompass not only relationships with patients, but also rela-
tionships with our students, colleagues, and society as a whole (Cruess,
Johnston & Cruess, 2002). The writers argue that physicians (and argu-
ably all health-care providers) are both healers and professionals, and
that a “social contract” exists between physicians and society. This
charter embodies three fundamental principles: the primacy of patient
welfare; patient autonomy; and social justice. It entails ten professional
responsibilities to which physicians should commit: professional com-
petence; honesty with patients; patient confidentiality; maintaining
appropriate relations with patients; improving quality of care; improving
access to care; just distribution of finite resources; scientific knowledge;
maintaining trust by managing conflicts of interest; and a commitment