Twitter and Facebook can affect the doctor-patient relationship

“I would be careful,” a fellow physician cautioned, as I told of my plans to attend a patient’s birthday party.

In my 12 years of clinical practice I have lived in the community in which I practice, less than two miles from my office. I encounter patients daily in the supermarket, at soccer games, swim meets and school events. I have had conversations with patients at parties, on the street, and while half-dressed in the locker room.

With my foray into social networking, beginning with participation in Facebook in 2008, I have “friended” my patients in cyberspace. As such, I have allowed patients to know details of my personal life and beliefs. They inquire about my family and are aware of my hobbies and interests. Perhaps against my better judgment, we have talked politics and health reform. But what are the appropriate boundaries?

Clearly the doctor-patient relationship is a highly privileged one, in which private and confidential information is exchanged. The communication that occurs within this context is subject to unique rules, ethical, and legal boundaries, as described by the Health Insurance Portability and Accountability Act (HIPAA). Patients share information with their doctors that they would not share with a friend, a neighbor, a fellow school committee member or another soccer parent. Should a doctor back away from a blurring of these boundaries?

Online social networking has introduced new aspects to this old question. Dr. Sachin Jain expresses it well in a New England Journal of Medicine perspective piece: “The anxiety I felt about crossing boundaries is an old problem in clinical medicine, but it has taken a different shape as it has migrated to this new medium.” Whether or not physicians should engage in relationships with patients within the context of sites such as Facebook or Twitter is a matter of ongoing discussion.

One blogger, Dr. Bryan Vartabedian, suggested that physicians might take the following precautionary measures to avoid trouble:

1. Have an offline discussion with patients who contact you via social networking regarding the confidentiality and privacy issues inherent in communicating in this manner.
2. Discuss with patients the need to document doctor-patient communication in the medical record.
3. Develop a personal social media policy to govern your interactions with patients via the internet and social networking sites.

These measures seem prudent to me.

Others have advocated that physician-users of Facebook have two pages, one personal and one professional. Those same physicians might hesitate to have coffee or dinner with a patient. Clearly Facebook and Twitter are never appropriate sites for discussing the details of an individual’s health or other information that could possibly be privileged and identifiable. Patients need to be aware that tweets show up on Google searches.

Does this mean I shouldn’t enjoy seeing pictures of a patient and her family, or getting to know her better through her status updates, sense of humor, likes and dislikes? In contrast, I believe that through this type of sharing the doctor-patient bond can be strengthened and trust enhanced. My view is that allowing some blending of doctor-patient-friend roles is likely to enhance the individualized advice that I am able to give my patients about their health problems.

With proposed changes to our primary care delivery model, “The Patient-Centered Medical Home,” we are looking at using electronic systems to care for populations of patients in part to compensate for inadequate numbers of primary care physicians. The proposed model would enlist care teams, including a single physician, to provide care for up to 5,000 patients (most primary care physicians currently care for two to three thousand). A system of automatic reminders, feedback on quality indicators, and decision support tools would ensure high quality care in this idealized model. But what happens to the doctor-patient relationship? So I say, lets not be so stymied by legalism that we are afraid to befriend our patients.

Juliet K. Mavromatis is an internal medicine physician who blogs at Dr Dialogue.

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  • Dr. Mary Johnson

    “Perhaps against my better judgment, we have talked politics and health reform. But what are the appropriate boundaries?”

    In terms of talking about the realities of healthcare reform . . .


    The patients/parents who have found my blog have been horrified by the story I tell, and have not always agreed with my opinions . . .

    , , , but almost all of them have told me that what I’m doing is important . . . and that it is “refreshing” to see a physician climb down out of the ivory tower, cross the boundaries (mostly imposed by antiquated notions on the physician side of that imaginary line), and BE REAL.

  • Astrid

    I am a patient. I don’t interact online with any treating physicians, but some of my other health professionals (nurses, psychologist, etc.) know about my blog and occasionally read it. Since I have a long-term experience with online interaction with people I have a professional relationship with (my high school tutor used to get virtually all he had to know about me from my blog), I know to be somewhat careful. Then again, I don’t want my family to know everything about me, either. ;) As for Facebook and Twitter, I don’t use FB and haven’t even tried to find my professionals on Twitter. They may read or even follow me, but for whatever reason, I consider it a little unethical to do it the other way around, esp. without prior offline, explicit consent.

    By the way, what is the problem with discussing politics with your patients? I discuss politics with my health professionals all the time, althugh in a GP consultation or the like it would simply be limited by time.

  • Angelique

    I am having visions of a board of medical administrators sequestered in an opulent conference room on the 200th floor of a Manhattan building demanding that a doctor in rural Idaho sequester herself in her home so that she never interacts with patients outside her office, thereby maintaining the same level of doctor-patient anonymity enjoyed by the participants in large managed-care clinics.

    I think your opinion of whether doctors should interact with patients socially will vary more depending on the circumstances of your life than any theory of boundaries. A doctor at a large clinic in a metro area has choices about getting to know patients better; a small-community doctor who sees patients every day out of the office does not unless he or she wants to act extremely rudely and/or become a hermit.

  • Juliet K. Mavromatis, MD

    Thanks for your thought-provoking comments. The issue of doctors discussing politics with patients is interesting. I think that people frequently bring up politics when they feel that the person they are engaging in a discussion likely has similar political views–as a way of establishing rapport. Politics can certainly be very polarizing, so I use caution when choosing it as a topic of discussion. Health reform is different. I do feel that it is socially irresponsible for a physician NOT to comment on this topic–though it too is divisive and polarizing.

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