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Posted by Lee Aase (@leeaase) · Thu, Aug 14 at 12:04pm CST

Should doctors or hospitals follow their patients on Twitter?

Brave New World: Your Doctor, Your Private Parts, Twitter And You

That's the underlying question Hinda Mandell, Ph.D. raised Tuesday in a post on the Boston Public Radio site, "Brave New World: Your Doctor, Your Private Parts, Twitter And You."

My gynecologist just followed my vagina on Twitter.  At least, that’s how it felt when I received email notification that I had a new Twitter follower.To be fair, maybe it wasn't my gynecologist who hit the “follow” button, but an employee at her practice. Does it matter? Because my ob/gyn’s name and Twitter handle are the same, and her Twitter avatar is her practice’s logo of a mother and child, entwined. Now she — or whoever her office’s social media manager is — knows my political views, sees the photos I take of my crafting projects and reads the recipes I plan to cook. It sounds innocuous, but it doesn’t feel so innocent.

Ms. Mandell refers to the 12-word social media policy published by our Mayo Clinic Center for Social Media Medical Director, Farris Timimi, M.D. (which is how I came across her post.) Dr. Timimi's personal policy is, in some ways, a distillation of our official Social Media Guidelines for Mayo Clinic Employees. The relevant point from our guidelines is this:

Mayo Clinic strongly discourages “friending” of patients on social media websites. Staff in patient care roles generally should not initiate or accept friend requests except in unusual circumstances such as the situation where an in-person friendship pre-dates the treatment relationship.

Does the different nature of "Friending" on Facebook as compared with following on Twitter make the latter less problematic? I think it does, to some extent. As Ms. Mandell says later in the piece:

What I find most confusing is my own reaction. It does feel unseemly, slightly freaky and certainly uninvited for the physician who helped bring my daughter into the world 13 months ago to know the Twitter version of myself.But why?

After all, I know on a conscious, logical level that my tweets are public and can be seen by anyone. I mean, isn't that the reason I use Twitter, to broadcast my ideas and opinions to a wider audience and to share the online content I find of interest? And if I already have a confidential, private relationship with a medical professional, who cares if she sees my very public tweets about the hottest Parisian beauty balms or chefs who have discontinued favorite dishes in New York restaurants?

She goes on to say that she does care and it makes her feel uncomfortable, and I  encourage you to read the whole thing.

In her doctor's defense, Ms. Mandell writes frequently on a public radio blog and has interesting things to say. To that extent, she's something of a public figure. Maybe the physician-patient relationship trumps that, but wanting to follow interesting and lively public commentary would at least be a reasonable explanation.

Which brings me to the main question, I think:

Why would you as a doctor, or as a hospital representative,
want to follow a patient on Twitter?

At @Mayo Clinic, the main reason we would follow a patient or employee is to enable private messaging.

In the early days of our Twitter experience in 2008 we weren't following anyone, but that seemed kind of...well...anti-social. Then we started following those who had followed @Mayo Clinic and who were real people and not spambots, until I got a message from a Mayo employee expressing some of the same angst at Ms. Mandell: "Why are you following me?" Felt we might be big-brotherish, I guess.

After that we moved to (generally) only following those who asked to be followed. If someone mentions @Mayo Clinic on Twitter, particularly with a service concern, we may attempt to connect by sending a private direct message. The NSA we're not.

What do you think?
Should providers following patients on Twitter be out-of-bounds?
What reasons for following might be justified?

I'm speaking next week at a Mayo Clinic CME event, Professionalism Today and Tomorrow: Sustaining Trust in a Technology-Driven Health Care World, and I would like to share the community thoughts on this, so would appreciate your perspective in the comments box below.

Updated (8/15/14): Dr. Bryan Vartabedian, a member of our MCCSM External Advisory Board, has posted on the topic this morning on his blog. Great stuff. Check it out!

Lee Aase is the Director of the Mayo Clinic Center for Social Media.

Farris Timimi hcsm patients Physicians TW

 

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Meredith Gould (@meredithgould) · Thu, Aug 14 at 12:18pm CST · #

Good, important, and necessary post, Lee. Let the conversation being...or continue. Turns out I'll be on a Stanford MedX panel about "Communicating the experience of illness in the digital age." My role is to explain how online digital has forever changed our cultural understanding, if not expectations, about privacy and self-disclosure.

In this particular instance, I'd say that because Ms. Mandell is a public figure, she has forfeited her right to what has heretofore been considered privacy. Plus Twitter, because of it's mini-micro blogging form, fleeting nature, and audience is substantively and substantially different from FB. I'd say following someone on Twitter is not equivalent to "friending" someone on FB. The very language reveals some key differences.

Of course I have much more to say on this matter. When do I not?

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Bryan Vartabedian (@bryanvartabedian) · Fri, Aug 15 at 1:11pm CST · #

I might add, Meredith, that being a public figure shouldn't necessarily be relevant. Twitter is a public platform and it has to be assumed by patients that anyone, doctors included, can see their tweets.

Then the question moves to whether a provider should be intentionally looking for information or conversations about patients.

Meredith Gould (@meredithgould) · Fri, Aug 15 at 1:43pm CST · #

You're right, of course. I was especially fascinated by her level umbrage which seemed odd considering her blogging. Also interesting as I look at it again is what David noted, that the post is classified as "Humor."

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Bunny Ellerin (@bunnyellerin) · Sun, Aug 17 at 10:30am CST · #

"In this particular instance, I'd say that because Ms. Mandell is a public figure, she has forfeited her right to what has heretofore been considered privacy."

Thank you, Meredith. Exactly. She has chosen to present her political views, craft photos and recipes to the world. If she wants to control who sees her message on Twitter, then she she should lock her account. Frankly I'd be more concerned if her auto mechanic followed her than her doctor - those peeps can do a lot more damage.

Greg Matthews (@gmatthews) · Thu, Aug 14 at 12:51pm CST · #

This is a really important issue, and I confess that I'm a little torn on the subject. Additionally, I think that the question is really different for hospitals as opposed to individual HCPs. I'll be writing something more substantive on this subject, but here's my thinking as it relates to doctors, specifically:
- I agree, of course, that doctors should never, ever engage with their patients in a public forum relative to that patient's health.
- I don't take any offense if my doctor doesn't choose to follow/friend me back for that reason - they need to maintain a really high wall to protect my privacy, their reputation, etc.
- If my doctor DID follow/friend me back, I'd be totally fine with that. I work with doctors who are interested in treating the "whole me," which includes pictures of my kids, embarrassing moments, rants and all. If my doctor cares to wade into that mess, godspeed to him!
- I absolutely follow my doctor(s) on twitter, because it helps me get to know them & their perspectives ... which ultimately makes me a better patient/partner in my care.
Having said all of that, I wouldn't counsel any physicians to follow or friend their patients proactively. In fact, I probably wouldn't counsel them to follow their patients at all. But I do encourage all doctors to follow PATIENTS (generically) because if they don't, they miss an amazing opportunity to learn from them. And if a patients follows/friends their doctor first, I think it's perfectly OK for the doctor to follow/friend them back - as long as they avoid the "never, ever treat or advise" rule above.

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Lee Aase (@leeaase) · Thu, Aug 14 at 12:55pm CST · #

Really well said, Greg. I think the key is to let the patient initiate the relationship. It's a variation on what we say for managers vs. employees. If the employee wants to friend the manager, that's OK...but the manager shouldn't initiate. Power dynamics, etc. That's one we more recently added as #8 on our Mayo Clinic employee guidelines.

Bryan Vartabedian (@bryanvartabedian) · Fri, Aug 15 at 1:17pm CST · #

I'd have to defer to David and the attys on this, but this patient initiation becomes important as it perhaps implies patient consent if I recall correctly.

Meredith Gould (@meredithgould) · Thu, Aug 14 at 1:24pm CST · #

"Whole me," Exactly. An integrated identity (online or off) is not necessary the same thing has having weak/poor/nonexistent boundaries.

David Harlow (@dharlow) · Thu, Aug 14 at 4:35pm CST · #

I commented directly on Mandell's blog post, and here's the same comment again:

This column is tagged "humor" by WBUR, perhaps because of the provocative first line. Assuming, however, that it is meant to be taken seriously, my first reaction is that an academic in communications ought to be able to toggle the privacy settings on Twitter if she were uncomfortable with being followed by persons who are not her real or virtual friends.

Moving beyond the details of this particular story, it is worth noting that even before we regularly referred to people's "digital exhaust," a physician in the UK's National Health Service who followed patients on Twitter told a patient during an office visit that the patient had misunderstood instructions on how to take a prescribed medication, and provided correct instructions again. The patient was surprised that the physician had picked up on this based on the patient's tweets, but did not seem concerned about the invasion-of-privacy sort of issues. See: The Case of the Twittering Kidney Patient: Healthcare and the Ethics of Social Media Monitoring – http://shrd.by/EnnrVa (from 2010).

Clinicians following patients on social media does not seem to me to be problematic. As this one NHS anecdote demonstrates -- and there are many other such anecdotes out there -- learning what the patient is saying and doing outside of the office visit permits the physician to get to know the whole patient. The value of this lesson is magnified when dealing with younger patients who -- it sometimes seems -- live their lives online, and are more open to communication online about general health tips (though not necessarily about personal health information in an open forum, absent appropriate consent).

I agree with the columnist's point that health care provider organizations should adopt and post external-facing social media policies. I would add, however, that it is just as important to have internal-facing policies governing social media use and engagement in greater detail. I do not believe that a policy would necessarily have avoided the columnist's "awkward situation." Posting yet another policy on a waiting room bulletin board is not going to educate anyone about anything. If a health care provider is serious about using social media to engage with colleagues, patients and the general public, however, then I believe that only good things will follow: greater openness, better communication and, ultimately, better health care.

In a small town, patients see their doctors at the grocery store and sometimes get a quick curbside consult next to the sweet corn. In the global village enabled by the interwebs, the power of the personal connection is magnified -- and the potential risks associated with using this power tool are greater. Even monitoring patients' public activities online, rather than engaging them, can yield insights about the whole patient not available to clinicians limited to the 12-minute office visit. Used carefully, health care social media can do a lot of good.

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Jason Slusarchuk (@JasonHoots) · Fri, Aug 15 at 8:56am CST · #

I think that as long as both parties are comfortable, go for it. Maybe it's a conversation physicians should bring up with their patients? To help the patient initiate a social connection, it would be great to see physicians pro-actively advertise their presence on social, encouraging patients to follow them. I wonder how many do this today?

Greg Matthews (@gmatthews) · Fri, Aug 15 at 11:55am CST · #

My doctor does! @DrJFrederick posts his blog URL and twitter handle in every exam room! In fact, I found him through his blog. He wrote about things that matter to me & my health, so I went in for a visit and he's now my PCP!

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Jason Slusarchuk (@JasonHoots) · Fri, Aug 15 at 12:15pm CST · #

Great story, thanks for sharing! A great example of how social media can be used to connect healthcare providers to patients and enhance the relationship.

I run a LinkedIn group dedicated to sharing stories about how social media can be used to advance healthcare and would love to share this story if you're comfortable with that?

Here's the group - https://www.linkedin.com/groups?home=&gid=6671832

Greg Matthews (@gmatthews) · Sun, Aug 17 at 10:59pm CST · #

Share away, Jason! DM me @chimoose if I can provide any more detail or context that could be useful.

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Bryan Vartabedian (@bryanvartabedian) · Fri, Aug 15 at 1:01pm CST · #

Lee, posted on this early this AM and just found this. Great commentary. I'll link over.

Lee Aase (@leeaase) · Fri, Aug 15 at 1:14pm CST · #

Thanks, Bryan. Love your perspective. I updated the body of the post to link to yours, too.

chaitanya (@urschaitanya) · 2 day(s) ago · #

Privacy violation.