You've just started treatment with a new psychiatrist, whom you like very much. Should you "friend" her on Facebook?
If she says yes, what if she finds those pictures of you dancing drunkenly with the lampshade on your head — after you told her you don't drink anymore? Or what if you discover pictures of her snuggled up with her husband and two adorable kids, when the reason you went into therapy in the first place was that you're sad about being single and childless?
If she doesn't respond, will you feel rejected, distanced, hurt?
And what about using search engines such as Google and Yahoo? What if your shrink Googles you to see if you're delusional or if you really are that famous astronaut you claim to be? What if she discovers that you have a posh address even though you pleaded for reduced fees? If she does Google you, should she tell you? If so, before or after? Should the search results go into your medical record?
One of the newest medical ethics dilemmas is the collision between the Internet and the traditionally strict boundaries between patients and doctors. Caregivers, especially psychiatrists and therapists, have historically disclosed personal information only when it might benefit a patient — as when a patient is struggling with the loss of a child and the therapist discloses that he, too, has experienced such a loss.
Likewise, patients have typically disclosed personal details in their own time, as therapy continues and trust develops. The Web challenges that model head-on.
Facebook, founded in February 2004, now has more than 400 million active users. MySpace, founded a month earlier, has 100 million. Google.com, the search engine founded in 1998, currently handles 100 billion searches per day.
There's no question that Internet searches can be an important tool for healthcare consumers. "Patients should Google their doctors, to check on credentials, training, scholarly articles and the like," says Dr. Daniel Sands, the senior medical director of clinical informatics for the Internet Business Solutions Group at networking giant Cisco Systems.
But what about the reverse — doctors searching patients? "Why would they ever want to?" asks Sands, also a physician at Beth Israel Deaconess Medical Center in Boston.
When it's OK to search
There may be times when it's appropriate for doctors to Google patients, says psychiatrist Benjamin Silverman, chief resident of the McLean Hospital adult outpatient clinic.
Silverman has a patient who stopped going to therapy without explanation. "I was concerned," he says. "I Googled her."
The patient was not upset, but Silverman felt he had crossed some kind of boundary. So he told her. "If we were going to continue treatment," he says, "I thought it was necessary for her to know that I had done this."
Other situations may justify an Internet search or a visit to the patient's social networking site as well, says Dr. David H. Brendel, an assistant professor of psychiatry at McLean. Maybe a psychiatrist suspects a patient has suicide plans, for example.
But doctors should ask themselves some hard questions before doing so, to be sure they are not just being voyeuristic.
"There are huge benefits to social networking," says Sands, but once you put information on such a site, "you are letting someone into your kimono, so you've got to be mindful about what's there."
And that goes both ways. Without revealing specifics, Brendel recalls a case in which a patient found information on a social networking site that "led to significant discomfort for the physician and the breakdown of their relationship to the point where the patient had to see another doctor."
Of course, Internet users can sign up for varying levels of privacy protection. Doctors can also simply refuse to accept requests from patients to be online friends. But many don't. A study of medical students and residents at the University of Florida in Gainesville, for instance, showed that only 37.5% made their Facebook sites private.
Sawalla Guseh, 25, a third-year student at Harvard Medical School and a Facebook user, says his view of social networking is changing as he goes through school. Two years ago, he says, "I was more, like, it's completely fine, not a big deal" to put his personal information on Facebook.
But when a fellow male medical student was "Facebooked" by a female patient who seemed interested in becoming involved in his personal life, Guseh became more conservative. "Nothing came of [the exchange]," he says, but it made him think. "As we accrue more responsibility… it's more important for us to be a bit more careful about who we friend and who we don't friend," he says.
It's about boundaries
Ultimately, issues of Internet searching and connecting must be judged by the fact that the relationship between a patient and a doctor should be "professional," says Jeffrey E. Barnett, a psychologist at Loyola University Marylandin Baltimore.
Among other things, he says, that means "you have to think carefully about boundaries" and to err on the side of avoiding certain types of "multiple relationships," such as being close social friends, business partners or, in the worst case, sexual partners. Such relationships can in particular threaten the trust that is the foundation of psychotherapy.
Trust would not be violated, on the other hand, if a patient and doctor or therapist sat down together to look at a patient's Facebook site, just as they might discuss photos or poems that a patient brings in. As long as the boundaries are clear, says Barnett, use of social networking sites or Internet searches shouldn't cause problems.
But distinctions can be subtle, says Sonoma, Calif., psychologist Ofer Zur, who discusses ethical issues on his website zurinstitute.com. He posts this advice: "Whether or not accepting the request [of a patient to be an online friend] constitutes a dual relationship depends on what kind of information clients are privy to and the nature of the therapist-client interaction."
As New Hampshire-based cancer survivor Dave deBronkart, who blogs as e-patient Dave about online health, puts it: "I have lots of personal information online, but I am keenly aware of the risks. The Internet is very, very leaky."
Read other articles by Judy Foreman at myhealthsense.com.