Medical Blogs: Social Contract?

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.