Everyone who uses the internet leaves some sort of footprint, even if it's just a string of visited addresses. This presence is magnified if you've ever been in the news, been listed on a website (e.g., as faculty), or if you write a blog. Social networking sites such as facebook and Twitter add a whole new dimension of online presence. Everyone should be concerned about what their online presence says about them (if your public Amazon wish list is full of sex toys, for example...) but physicians should have special concerns which fall into some broad categories. First, we'll briefly discuss types of online presence.
Your online life
Who hasn't vanity googled? Googling yourself can be interesting and instructive. If you have publications, are listed on a website as a contributor to a charity, or anything else searchable, someone can find this out. It's probably better to find out for yourself before you hear about it. As mentioned above, public profiles and wish lists at places like facebook, Amazon, and eBay are often included in search results, as are basic components of facebook profiles. Your online presence is dramatically larger if you are involved in web-related activities such as blogging. Even if you blog anonymously, it's likely that eventually, a search will link your real name to your blog and everything you've written there even if you've deleted it. Different types of online presence present different challenges.
- facebook: parts of your profile are visible publicly, and depending on your privacy settings, a great deal of information about you is visible to "friends" and many other members. Critically, this includes your status updates. If you write, "I LOVE CHEEZE!!!" people may think you quirky, but there's little harm. If you write, "I LOVE BONG HITZ!!11!!!" this is information that is going to be available to many others, and there is a good chance that it may become available to colleagues and patients. This would generally be a bad thing.
- Twitter: twitter is like having only the status updates from facebook, but relationships with other tweeters tends to be looser, and many people have hundreds of followers whom they do not know.
- MySpace: if you are on MySpace it's probably past your bedtime (or you're on a special "list").
- Blogs: blogs contain an enormous amount of information about how you think and what you believe, and this information is, for all intents and purposes, permanent.
(NB: I am not a lawyer! This is simply an introduction to these ideas and should not be construed as legal advice. Really!)
Most non-physicians who maintain an online presence have no legal fears (other than behaviors such as libel), but doctors most certainly do. The Health Insurance Portability and Accountability Act (HIPAA) is the law that governs the privacy of your medical information. It is very, very detailed, and requires quite a bit from your doctor. You've signed a form at the office of every provider you've visited that notifies you of your privacy rights. I cannot discuss your care in a hospital elevator. I can't send you an email regarding your health without making it very clear that any information in the email cannot be considered secure. I cannot disclose your health information to anyone else except under very specific and limited circumstances. HIPAA has radically changed the way we do things with health information. Information covered by HIPAA is known as Protected Health Information (PHI), and knowing what is and is not PHI is sometimes unclear, but some things are rather obvious.
If you facebook, tweet, or blog about a patient without their specific permission, you could be in big trouble. HIPAA covers any individually identifiable health information, so if I were to publish that the incidence of chlamydia is x%, no one is harmed. If I were to write that four of my personal patients had chlamydia last month, that's getting a little close to the line, and if I were to talk about a young man who works as a clerk who had chlamydia last month, I've probably crossed the line. That's why I don't write more clinical anecdotes, and when I do, they are amalgams of patients seen over the years rather than a single individual's story.
Hippocrates of Kos (probably) wrote this about 2400 year ago, and despite vast differences in cultures, confidentiality is a widely accepted medical ethical principle. There are many good reasons for this, but the essential point is that revealing anything about patients in online venues is not just unwise and potentially illegal, but also unethical. It damages the doctor-patient relationship, the emotional integrity of the patient, and the reputation of the doctor.
Doctors have a professional identity which they must guard closely. Just as it's unwise for a doctor to been seen grossly intoxicated in a public place, unprofessional comments online can destroy your reputation. Strangely, quacks never seem to mind promulgating bizarre hypotheses publicly, but their reputation is based on deception of individual patients rather than the opinion of the community. Your reputation as a physician is much more sensitive, and you must guard it jealously. A facebook picture of you prancing around a nude beach can do damage well beyond the "ick" factor.
But what if no one knows who I am?
The saying goes that online, no one knows you're a dog. But anonymity is a very thin veil. If you use your anonymity to protect you, your patients, your hospital, or your practice, all you have done is delay a big problem. Your cover can be blown at any time. Now anonymity and psuedonymity can provide something. They may (maybe) put your name one or two clicks further into a google search, and it creates an online persona that can be managed separately from your real identity. But never forget that these identities will likely merge at some point, either through carelessness, spite, or chance.
In medicine, your reputation is everything. Bad doctors with good reputations do very well, and good doctors with bad reputations starve. How you conduct yourself online is part of building this reputation. Being online can be very rewarding both personally and professionally, it just requires caution and forethought. Every doctor should think very, very hard before they push that "enter" key.