Lab coats optional on Web ‘rounds’
For physicians of a certain age, the weekly teaching session known as grand rounds is a ritual steeped in formality and tradition. Presided over by the profession’s graybeards, grand rounds are attended with white coats on and clinical details in hand.
Here, young physicians learn to accept their elders’ old-school admonishments with reverence and humility.
Grand rounds on the Internet, however, is another thing altogether. A weekly compilation of the Internet’s best medical blog postings, it is part classroom, part locker room, part group therapy session and part office party -- a free-wheeling collection of rants, shop talk, case studies and learned commentary (along with the occasional recipe, movie review or vacation slide show).
This rotating Internet roundup, hosted each week by a different medical blogger, is the center ring of a colorful and growing circus of blogs written by medical professionals and posted for all to see. It is making the practice of medicine more transparent to patients and, at the same time, raising ethical questions about safeguarding patient privacy.
“Medical blogs have the opportunity to be such a benefit to patients,” says Dr. Tara Lagu, author of an article on the subject published online last week in the Journal of General Internal Medicine. “By revealing the struggles we have, they can really open patients’ eyes to how to interact with doctors, they can connect patients and nurses who can be isolated from each other and they can be an important source of information for doctors as well as patients.”
But as physicians increasingly use blogs to talk shop and vent their frustrations online, patient privacy has become an issue, says Lagu, who is a Robert Wood Johnson Foundation Clinical Scholar and an internal medicine specialist. “It’s time for us to take some responsibility and really think of how we can maintain the integrity of this process.”
The Health Insurance Portability and Accountability Act, or HIPAA, gives patients strong privacy protections, but the 1996 law predates the medblog phenomenon, leaving gray areas for bloggers who write about their patients.
In a 2006 study, Lagu and her coauthors found 271 blogs written by physicians or nurses. Roughly 42% of those blogs included descriptions of interactions with individual patients, and almost 17% “included sufficient information for patients to identify their doctors or themselves.” Three of the blogs showed recognizable photographic images of patients.
And in a sign that blogs may increasingly become a means of indirect marketing by pharmaceutical and device makers, 11.4% had postings promoting healthcare products. Few, however, said anything about an author’s conflict of interest.
Medical blogs are the place to eavesdrop on what doctors and nurses are talking about in break rooms and at conferences and to read what medical professionals think about the latest clinical studies or healthcare proposals making headlines. For a growing number of the nation’s more than 700,000 physicians and 2.9 million nurses, they are a gathering place like no other.
Here, members of the community jettison the facade of clinical authority; abandon forbearance with obstinate or demanding patients; and flout the convention of paying homage to the profession’s most senior practitioners.
“Like everything else on the Internet, it’s just kind of the Wild West,” says Dr. Allen Roberts, an emergency room doctor from Fort Worth who is better known in the blogosphere as the author of the GruntDoc blog. “It’s very leveling . . . you can write in print what you would never say to a surgeon’s face about him being an overweening jerk.”
Though many medblogs are filled with clinical observations and links to studies, some posts are deeply personal and often downright ribald.
In a recent Friday night posting on the blog Ob/Gyn Kenobi, an obstetrician who identifies herself as Dr. Whoo admonished pregnant patients -- under the heading “Seriously, people . . .” -- not to place an emergency call to the doctor if they had just had sex and had a creamy discharge (but no pain or bleeding) afterward.
“It is semen, you rocket scientist, and we really, really did not need to know that,” she fumed on the blog. “Think before you page,” forcing doctors to take time away from family and home “to hear about the effluent from your nether regions after your feelgood Friday night.”
A growing number of people -- by no means all of them medical professionals -- seem to enjoy reading the unfiltered candor of a profession long hidden behind the white coat and forbidding air of authority.
“It really gives a glimpse behind the medical curtain that otherwise the general public wouldn’t see,” says Dr. Kevin Pho, an internal medicine specialist in Nashua, N.H., and author of the widely respected blog Kevin, M.D. “Some of the opinions are very raw and in some cases don’t reflect on the profession in a very positive way. But they do reflect reality; we often say what people don’t like to hear.”
When Roberts -- GruntDoc -- sat down at his computer in 2002 and began posting a running commentary on his professional life, he knew of four, maybe five, other physicians doing the same, he says.
Today, the world of medical blogs is a place so crowded that Roberts says he doesn’t know most of their authors. According to Lagu’s analysis, roughly 65% are penned anonymously, while the rest of the authors identify themselves by name. Some use their blogs to blow off steam and share their experiences in a profession that most agree has become more trying in recent years; others use it as a link to studies they find interesting; about half, Lagu says, make forays into the political realm of healthcare policy; and a few, including one sponsored by the highly respected Cleveland Clinic and Case Western Reserve University, are primarily teaching tools.
But Lagu says physicians who blog may not be doing all they can to protect the identity of patients described in postings. She cited several cases in which patients had been disparaged by disgruntled physicians. Her study also found 45 blogs -- 16.6% of the 271 she combed through -- that included posts describing interactions in enough detail that patients, or family and friends, could recognize themselves.
Several bloggers interviewed said they are wary of identifying patients and take pains to avoid it. Roberts says he frequently changes the gender, age or other descriptions of patients. Dr. Robert Donnell, a hospital-based physician in Arkansas who writes under his own name at Notes From Dr. RW, says he avoids reference to any clinical cases in which he’s been personally involved.
Virtually every medical blogger acknowledges in his or her posts the case of Flea, a physician blogger who anonymously posted on his practice, including damning details of a malpractice suit against him. In the course of the case, the plaintiff’s attorney -- recognizing the doctor by the details in his posts -- confirmed he was the author and used his own words against him.
Lagu says that bloggers’ intentions are mostly good, but it’s not clear all are doing enough to protect patients’ privacy and to avoid undermining patients’ trust in physicians.
Experts fear, for example, that commercial interests could damage the integrity of the medical blogosphere unless the profession agrees on when and where a blogger’s conflicts of interest should be divulged. Tom Rosenstiel, director of the Washington, D.C.-based Project for Excellence in Journalism, says public relations firms are known to have some bloggers on retainer to ensure favorable mentions of their clients. And Lagu cited an online survey of healthcare bloggers, in which 29% of respondents said they had been approached by public relations professionals to endorse certain products. The survey, prepared by the commercial group Envision Solutions LLC, also found that 52% had written at least one post endorsing such products.
Medical blogging is such a new feature, Lagu adds, that it has scarcely been noticed by the profession’s graybeards -- medical community leaders who would ordinarily initiate debate on appropriate behavior of their peers. Amid that leadership vacuum, she holds, the medical blogosphere has become much larger and more cacophonous, and patients’ medical secrets are clearly being spilled in the process.
For links to the blogs that are mentioned, read this article online at latimes.com/health.
The patient is thriving! Come check the vital signs of the medblogosphere (if that’s a word) at latimes.com /medblogs.