Mexico Medical Student

Medical Blogs: Social Contract?

(No Ratings Yet)

Loading ...

In the October 2008 issue of the American College of Emergency Physicians’ (ACEP) Journal, an op-ed was posted entitled “Medical Blogs: Communication Vehicle or Social Contract?” (if the link takes you to a sign-up page, close the window and click it again–there’s a strange cookie that’s set that will bypass the registration screen) As I read it, the first thing that struck me was the comically dated language and information. The death knell of this article’s significance was already ringing in the first paragraph (all emphases below are mine):

According to the Internet phenomenon Wikipedia, blogs (short for Web-logs) are Web sites, usually maintained by an individual, with regular entries of commentaries, descriptions of events, or other materials such as graphics and video. They can serve as online interactive diaries where bloggers pour out ideas, feelings, and opinions, and invite readers to respond with comments of their own that are often equally fascinating and spontaneous.

Technorati, a blog searching service, reports there were 112 million blogs in 2007.

Wikipedia is relegated to a “phenomenon?!” Someone needs to tell these folks at ACEP that they don’t need to qualify what a blog is with enumerated reference; it’s not 2005, and wasting a paragraph on the obvious made me want to stop reading altogether.

Moving on, any person in the blogosphere worth their salt knows the once mighty Technorati has long since lost almost all of its relevance. Nobody uses it for anything useful, its continued existence being somewhat of an anachronism. However, the ACEP authors cite 2007 data from it in July of 2008!!(as referenced in the footnote) WTF?! They aren’t even trying to appear as though they care at this point.

The painfully protracted exposition continues:

[Other blogs] serve largely as public journals, providing authors’ insights and anecdotes without the peer review or editorial vetting that occurs in more traditional journal venues. However, the personal nature of many blogs lends them an intimacy and an immediacy that is often missing from mainstream outlets. Arthur Caplan, a prominent ethicist, compared blogs to an extended form of chatter and conversation.

I noticed here already a condescending tone that would get more and more pervasive throughout the article, that the notion of a peer-reviewed journal is the pinnacle of scholarship and a blog being gossip and nonsense. Wrong and wrong–it’s a comparison of apples and oranges. No one would argue that “big” journals get their gravitas from their editorial boards, but even peer reviewed journals suffer from bias, politics, and other non-scientific factors, and published studies often come under fire after publication for being extensions of corporate/non-scholarly interests. On the flip side, many blogs can honestly stand against some of the giants of the print world in terms of their solid content–far from idle prattle–the “peer review” being the entire world of reading scholars, all free to leave commentary, positive or negative, in an open forum.

It is this point in particular where the “good old boy” stripe of physician is most chafed. There’s a strong sense of “you kids get off my lawn!” as a new medium threatens to tear away the fabric of order and control as seen through the eyes of these authors. The very notion that a patient or layperson has a potential standing of equivalence to published physicians is the fundamental reason behind why this article is being published in 2008 without embarrassment: the ACEP still doesn’t “get it.”

Most of the above is petty quibbling compared to what I’m going to quote here, though:

Dr. Rita Charon, a physician and a leading authority in narrative medicine [whatever the hell that means], believes patients own their stories, and she takes the strong position that physician-writers must have patients approve narratives written about them before publication. Two other writers and experts in literature and medicine - Dr. Jack Coulehan, internist and poet, and Ann Hawkins, Ph.D. - invoke the argument of relational ethics. What will happen if particular patients discover that they were featured in an article, story, or blog? Will they find such attention beneficial, perhaps therapeutic? Or will embarrassment or betrayal boil their blood?

“Patients own their own stories?” Well, yes, in a fundamental ethical way, no one would argue that it would be wrong to publicly share that which is private between doctor and patient. In today’s world, HIPAA guarantees*cough* that their information is kept confidential, and every medical blogger I know goes well out of their way to mask any indentifying features of a story so that any semblance to the original would either be complete coincidence or not specific enough to be unique (”a woman came to the ER last night” would apply to potentially half the emergency patient population, for example, even if it were found to be true). However, the authors aren’t even bringing up confidentiality or legal concerns; they are ridiculously invoking the idea that in a doctor-patient encounter, the patient is the “owner” of the encounter’s narrative.

RUBBISH!

There isn’t ONE story, but TWO stories, at least: one from the point of view of the patient, and one from the POV of the physician. The ACEP doesn’t seem to be concerned with nurses, techs, etc. but the reality is that everyone in, say, a trauma bay (this is the ACEP after all, and ER environments are hardly ever private one-on-one encounters), could feasibly walk away from that encounter and have something to write about and each would be unique representing a distinct POV. You can’t equate or assign ultimate ownership of the experience of any one person, the different jobs being performed, etc. It is the height of arrogance to say that any one person actually “owns” the unique narrative of another. It’s sickening, in fact.

You have to hand it to bioethicists, though. I love that they exist, and like the ACLU, you’re happy they’re there for the “big stuff” that require their unique talents, but like this they’re often involved in issues more for the intellectuo-ethical ~~masturbation~~ debate than for yielding something tangibly better for the patient.

There’s a lot more as the article continues about what kind of “tone” the physician-blogger should strive for, and other paternalistic drivel from authors who have already demonstrated their incompetence on the subject matter. It’s insulting enough as a physician reading this to be told they “should aspire to a voice that is respectful and professional,” much less by these authors who can’t even utilize the very tools they are professing to teach.

Ultimately, however, the relevant question is raised, “What kind of ethical code should be used to protect patients’ confidentiality?” Had this not been the article of two online amateurs, the last section could have served as a wonderful teaching tool. Instead, it turned into yet another demonstration of hubris demonstrating, “Look how I’ve offered a solution to this problem!”

The solution for a “code of ethics” had already been actively addressed, voluntarily, in the medical blogging world, without the need of paternalistic mandates from out-of-touch organization chairpersons. The Heathcare Blogger Code of Ethics (HBCE, also knowns as “Medblogger Code”) was created by communal referendum with each blog’s participation vetted beforehand. Nowhere in the HBCE will you find paternalistic directives like “Wait one week before posting [clinical encounter] material to your blog.” We (and I say ‘we’ because I’m an active member in this community) assume that bloggers who care enough to announce due diligence with the HBCE badge don’t need to be micromanaged about their own posting habits, timing, or frankly judgment on any subject.

In fairness, I’d love to see what these two ACEP bioethicists would make of the HBCE and even the sibling patient-focused community, the Patient Blogger Code of Ethics (on the same site above). Perhaps that can be the subject of a future article, once the authors get this whole “blogging” thing down.

Tags: bioethics, blogging, emergency medicine

'Net Finds, Blogging/Web2.0, Medical and Health | enrico | November 10, 2008 11:30 pm

8 Comments

By Vijay, November 11, 2008 @ 7:22 am

If this is the establishment’s view of blogging, I wonder what they think of twitter, friendfeed, et al!
On a personal note, why the F don’t you write such meaningful stuff more often instead of addling your few remaining functional brain cells with Tequila
By rlbates, November 11, 2008 @ 8:48 am

Enrico, when I read that article, I too thought “what about my story?”. Aren’t we taught from early on that there are always two sides (and often more — think the family of patients side, the other care givers, etc here) of a story. Shouldn’t we be telling all of them. Oh, wait that’s what blogs do.
By dragonfly, November 11, 2008 @ 10:10 am

Well said…
By dragonfly, November 11, 2008 @ 10:11 am

I also wonder when hospitals will start adding a “no blogging allowed” clause to employment contracts.
By buckeye surgeon, November 18, 2008 @ 7:10 am

Nice work Enrico. That ACEP article is post modernist, meta-analysis b.s. at its finest. I love that there is an authority in “narrative medicine” lurking amongst us; high comedy.
By Bruce, November 29, 2008 @ 11:48 pm

Dear Enrico,

I get a completely different take from the editorial than you do! However, I believe that you and the editorial writers share many views in common.

To me, the point that they are making is that the blogs DO change the way information is processed and presented. They point out, as you would agree, that “The ease and accessibility of blogs have altered the hierarchy of influence and power.” They are, I believe, confirming what you imply - that the balance of influence between the “traditional” medical media and the medical blogs is rapidly shifting.

That said, the editorial is a sharp reminder that bloggers can be too easily drawn into places where patients’ privacy can be compromised and unanswered ad hominem attacks can occur. The peer-reviewed journals have long since addressed these issues; when I published an essay in JAMA last year about a patient, they required a signed release even though there was only an oblique possibility that the patient would recognize himself. Had I posted the same story on my blog, there would have been no such requirement.

So, I guess I am saying that the editorial’s writers are acknowledging what you already know: The blogs are important, growing, and increasingly influential. Blogs have yet to universally recognize the need to be uncompromisingly responsible. Dr. Rob has taken us all in that direction by developing the HCBE.

As a disclaimer, I have met Jay Baruch - he is an accomplished teacher of the Medical Humanities and a terrific writer (check out his remarkable book Fourteen Stories). Nevertheless, I applaud their Society’s Ethics Committee’s willingness to take a stand on the need for guidelines for their blogging members. Emergency Physicians and Nurses seem to have a disproportionate presence in the blogoshere.

Sorry to go on so long, but your thoughtful piece deserved a response. Thanks!
By enrico, November 30, 2008 @ 5:11 pm

Dr. Cambpell: And your thoughtful comment also deserves a reply! All I’ll say is that what rubbed me the wrong way was that however well-intentioned the authors on the subject (and nobody, least of all me is questioning their medical/ethical POV), the piece just felt like a poorly-researched/understood position paper. Add a paternalistic overtone to it–particularly about ownership of an “experience”–and it was an easy target. On that note, I probably was picking a bit too harshly for the sake of a more scintillating post, but I think you’d agree that the ACEP, like many professional organizations, are slow on the uptake in this area.

I doubt that peer-reviewed journals are going away even in my lifetime, but scientific publishing is trending away from a closed review process towards a more open one. In all areas of life, people increasingly and willingly are giving all sorts of personal information the probably wouldn’t even 10 years ago for the sake of convenience, and while I do think that due diligence for privacy concerns ALWAYS needs to be in place, for better or worse, the overall trend in all sectors is transparency, openness, and free collaboration. The authors didn’t represent the opposite by any means, but forward progress can be halted by many little weights, I suppose.

Anyway, at this point I think I’m more musing than responding, so I’ll leave it at that. Thanks for sharing!