Facebook friend issues between doctor and patient

My friend and colleague Katherine Chretien has a provocative op-ed in USA Today entitled, “A doctor’s request: Please don’t ‘friend’ me,” which asks the question whether doctors and patients should interact in social networking sites such as Facebook.

Social networking has huge potential in health care regarding the sharing of information and ideas, and could possibly even enhance communication between doctors and patients. However, as Dr. Chretien points out, many physicians have steered clear of social networking sites, and those who do, “actively dread having a patient add them as a friend.”

The main problems with social networking and patient-physician interactions boils down to confidentiality, security and boundaries.

Confidentiality and security are less murky issues to deal with, and is applicable to all online communications between doctors and patients. First, there has to be privacy. If a patient wants to post their entire medical history to the world, they have every right to do this, but doctors have to ethically and legally maintain a patient’s privacy. This should not be too difficult, but could get tricky in a social networking world.

If a patient posts “Not feeling well today,” a reply from their physician “don’t forget to take your meds,” would likely be a violation of privacy and confidentiality. In addition, all online communication must be secure. Regular email does not even meet that requirement.

In fact, unlike email, both parties need to be logged in to Facebook to send and receive messages, making Facebook a better choice for direct communication between doctors and patient then regular email. Part of security also means encryption. According to Facebook they “always posts to a secure page when users are logging in and employs industry standard encryption.”

The bigger problem has to do with boundaries. The doctor and patient relationship is unique in that is should be close and personal, but if too close, the doctor’s objectivity could be compromised. This is why it is considered unwise (and sometimes unethical) for physicians to treat their relatives. According to Dr. Chretien, “the thought of opening up our personal pages filled with family photos, off-the-cuff remarks and potentially, relationship status and political and/or religious views to our patients gives us the heebie-jeebies.”

However, is having family photos online any different than having family photos in one’s office? Does an off the cuff remark revealing a physician’s political slant any different in the office than on the web? Physicians are often known to personalize their office space with items of personal importance and significance. Family photos, an artifact from a vacation, a golfing trophy, a treasured gift from a patient, I believe this is a good thing. It humanizes physicians and hopefully assists patients in making connections with us.

The two problems with Facebook are controlling one’s own privacy and the use of the word “friend.” Facebook was founded by Mark Zuckerberg with his college roommates and fellow computer science students. In other words, it was invented by kids. The term used to link one another is “friend.” However, this is not “friend” the noun which we are all familiar with, but rather “friend” the verb. Though “friend” the verb can theoretically used to mean “befriend,” in conjunction with Facebook it is the mechanism by which one connects with another individual online.

The confusion is not unique to the doctor-patient relationship. I am sure many young adults wonder what to do when a parent “friends” them. If instead of “friend”, Zuckerberg and colleagues had used the word “connect’, we would probably be less concerned about boundary issues. Is it wrong for a physician to “connect” with patients online?

The issue of controlling one’s own privacy is likely what truly concerns many physicians when considering using social networking platforms like Facebook with patients. After all, the physician who personalizes his or her office space has carefully decided what he or she wants patients to know about them. Even if a physician is careful in posting information on Facebook knowing that patient-”friends” might see, other non-patient “friends” can tag the physician in a compromising photo or leave an inappropriate reply that could be easily viewed by the patient. This is obviously a barrier, but this barrier is easily overcome.

The easiest way to avoid this problem is to have two separate Facebook accounts: a professional/patient account and a private/personal account. A variant of this would be setting up a “Fan” page. Finally, any Facebook user should be familiar with the privacy settings on Facebook. These can be customized. For example, you might create a groups called “patients”, “relatives” and “close personal friends”; assigning different permissions to each of these groups.

As the op-ed points out, there are currently no national guidelines for social media use by physicians and, as mentioned above, confidentiality and boundary issues are difficult and controlling one’s own privacy may not be easy for many physicians. However, most of the barriers for using social networking between doctors and patients can be overcome. Given that, and the potential uses and benefits social networking can provide, I would somewhat disagree with my friend (correct usage of the noun) that physicians shouldn’t be “friends” on Facebook with patients.

However, if they do, they should proceed with extreme caution.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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  • http://fertilityfile.com IVF-MD

    Definitely keep patients on your professional account only and off your personal account. I agree that a lot of good can come from the proper use of social media with your patients. Nice article.

  • BladeDoc

    Is “actively dread” a bit of hyperbole? The ignore button is right there.

  • http://kitatakegroup.com Constance Kitatake

    Excellent post Dr. Mintz! Many physicians feel blind-sided by social media, especially those in their fifties. It’s critical to delineate between a business presence and personal pages. Physicians are particularly vulnerable to internet defamation given their investment to be in practice in the first place, and in some cases treating patients who blame the doctor for their pain and disappointment. I think many physicians are waiting on the sidelines for guidelines

  • http://philbaumann.com Phil Baumann

    Matthew –

    Well stated.

    There definitely are important issues that need to be recognized, processed and addressed. I think extreme positions either way probably aren’t realistic.

    And yet: it’s a sticky issue for the reasons you mentioned. And Facebook – though popular – wasn’t designed for these kinds of relationships. Not to mention, Facebook as software is very unstable: one simple change in the software can produce major ramifications in the social ecosystem – from Privacy to social relations.

    I’d also have to echo your sentiment on Boundaries. I think it’s Boundaries that we need to really understand and workout – it’s a lot easier to violate boundaries on Twitter and Facebook than IRL (“in real life”).

    My view is that more providers – nurses & doctors – need to participate in the public discussion about how best to take advantage of emerging media while realistically and responsibly addressing the key concerns.

    @PhilBaumann

  • http://www.foxepractice.com Audun Utengen

    This is a very debated subject, and rightfully so.

    The Social Media Policies we implement for our medical practice clients address this issue directly. This is how we do it:

    - We encourage patients to become “fan”, now “like”, our medical practice Facebook page.
    - No provider/staff should be “friends” of a patient.

    This limits the communication to only public conversation, which also help the physicians to only communicate general medical information – which does not constitute medical advice.

    Although this may change sometime in the future, at this point we do not want any medical advice be given over social media.

  • W

    I was once referred to a surgeon who is good friends with my boss and with an employee I supervise. It made for a nice ice-breaker at the first consult, but before long it became very obvious (based on questions being asked by my boss and my employee) that they enjoyed a different standard of service — for example, they received post-op phone calls from the surgeon himself, rather than office staff as I did, for the same procedure.

    I’m sure the care was equally good, but I felt uncomfortable having to admit that “no, Dr. X did not call me” or “no, Dr. X did not tell me that joke”…etc. Even worse was having to hear about his personal life…stuff like “his wife has a tattoo”. Too much information…

    I don’t think it’s reasonable to ask doctors not to treat their friends differently. I just didn’t like having my nose rubbed in it. Maybe those who do receive “professional courtesies” could be reminded that they should be somewhat discreet?

  • http://fertilityfile.com IVF-MD

    This brings up another question.

    What advice is there regarding people who are friends first and then later become patients?

    Hypothetical examples:

    What if my classmate from medical school wants to come see us for treatment?
    What if my billing manager’s neighbor or my nurse’s brother wants to see us?

    Do we just universally turn them away to avoid conflict of interest or can we help them, but just be extra cautious in our interactions? If so, what extra precautions should we take? Are there any reasons that prevent us from choosing to treat them pro-bono if we decide?

  • http://cocoonhealth.co.uk/ Jays S

    Well written post. Although I’m not a doctor I often have the awkward task of ignoring my clients’ invitations to become ‘friends’ on facebook. It just shows how inappropriate that word has now become. But it also shows how loose our interpretation of the word is.

    Surely all our relationships are determined by two things: intimacy and privacy. Facebook offers neither but it does serve the purpose of ‘keeping up with people’. The thing is, I would rather keep up with clients via email and telephone than on facebook.

    Surely there are better networks for the doctor-patient relationship. Anyone have any suggestions?

  • http://www.lisastockwell.com Lisa Stockwell

    Facebook can be beneficial as a marketing platform for health care providers, but I’m not convinced it’s the right venue for enhancing physician-patient communication.

    The problem I see with Facebook is that it is becoming so commercialized that it doesn’t feel as much like the “friendly” place it was when it was starting out. My sense is that people might prefer to go to a dedicated health-oriented community when they want to discuss their health (as they do now when they join forums).

    I’m interested in the idea of creating social networking communities similar to Facebook’s in local networks created by hospitals or clinics. These would be online communities where the affiliated doctors, nurses and hospital staff can connect with patients. The network would be limited to those in the region served by the hospital. And the subject matter would be limited to health questions and concerns (clearly stated when you log in that this is for general info and not medical advice). If the software was similar to Facebook’s then there could be a direct message option that would allow people to communicate directly as well as by posting public comments.

    A local online community could not only help patients manage their own care and build trust in their healthcare providers, but might build a better sense of community between area doctors in a way that strengthens the referral system.

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