How do we keep the human presence and perspective, as well as humanity, inside the personal conversations that take place in medicine? As physicians, our ability to listen, empathize, and communicate our observations, reasoning, and knowledge in a thoughtful way is our most vital tool. While the electronic universe has given us unbelievable advantages, it does have its downsides. Even those working within the profession of medicine may sometimes appear to be more worried about efficiency, data analytics, and the use of the latest technology than the comfort and care of humans. Perhaps we know we should be talking more and typing less, and observing longer, listening deeper, and reducing the time we spend clicking, tweeting, and blogging. We need to remember to utilize other opportunities to gather knowledge and connect with each other than through an electronic screen. But how can we compete with the virtual, seductive, endless, immediate, and often essential information now available at our fingertips? Once we have the knowledge and expertise we need, what will prompt us to close our computer screens, turn away from our electronic devices, and open our eyes, ears, and hearts as humans and as caring doctors? Or can we devise ways to retain our compassion and care as we hold the computer in one hand and the patient in the other?
There are few aspects of society, including clinical medicine, still untouched by digital communication and the Internet. It seems harder and harder to think of daily interactions or common transactions we all have, inside or outside the clinic, that are not conducted, facilitated, augmented, or wholly reliant on computer screens. Try to identify pockets of your life untouched by the Internet, and you might find a challenge. There are very few service economies we use, or personal and professional interactions we have, including those in healthcare, that are free from the Internet and independent of electronic screens.
It would seem that the important and intimate conversations in a doctor’s office or at the bedside should be one of the last refuges to provide private face-to-face discourse between two humans, free of the distraction and the distance of the computer. But, as we all know, that is changing. From computers in the exam room to electronic medical records, to email exchanges and texting with patients, computers are ever present in the delivery of healthcare. Imagine removing all of the familiar aspects of human communication, from verbal to nonverbal cues, facial expressions, body language, attentive listening, clear articulation, important pauses, observations, empathy, natural vocal tones, eye contact, human touch, and the use of instinctive physical gestures. When you remove the human elements of traditional communication, you will unfortunately find yourself in a world where more and more people, including physicians and patients, interact, gather information, and express themselves daily through technology. Welcome to the world of digital communications.
Of course, information technology has revolutionized medicine, and the advantages for patients and physicians are numerous. Through patient computer portals, patients can now look at their lab results and treatments and ask relevant questions; physicians can respond quickly to emailed questions; and patients can inform themselves about surgery by watching online videos, see their x-rays, and have more informative conversations with their doctors. Apps can monitor our physiology; robots can deliver medication and perform surgery; and artificial intelligence is playing a bigger role in the analysis of complex healthcare data.
Today, patients show physicians pictures on their cell phones of the rash they had last week or an x-ray from another hospital. A retired college professor related a story to me about how his cell phone changed his spouse’s scheduled lumbar puncture (spinal tap) in an emergency department. He recalled, “The docs were not aware that she had had major spinal surgery in the past with a metal plate in the region of L4-L5.” But her record and x-ray were on his cell phone. Once he showed the doctors the x-ray of his wife’s spine (Figure 2.1), it altered their approach. She immediately went down for a fluoroscopically guided lumbar puncture instead of the doctors performing it at the bedside. Fortunately, all went well, and the results from the lumbar puncture were negative.
The quick adoption and global reach of this relatively embryonic technology of Internet communications are astounding—from cell phone data exchanges to live streaming interactive videos and other electronic forms of communication. The impact and influence on individuals, societies, and professions, including medicine, may exceed some of the most significant media inventions over the last 600 years, such as Johannes Gutenberg’s printing press of the 15th century, Samuel Morse’s telegraph and Alexander Graham Bell’s telephone of the 19th century, and commercial television of the 20th century.
Today, whether our chosen form of social communication is a blog, a tweet, a text, or an email, our electronic correspondence tends to be brief, unedited, unfiltered, and public. The speed with which we send and expect to receive electronic signals and manage electronic data is no less than astounding. We don’t seem to mind that our digital communication is more of a brief monologue and less a thoughtful human dialogue. For some, “likes” and “dislikes” or illustrations of thumbs up or down seem to have replaced any in-depth response or true discourse. Tweets have become the equivalent of a sandwich board or political placard. Blogs are how we stand and shout in the public square. Instagram is how we share a picture of what we are eating, seeing, or wearing. There seems to be little time or space for deep reflection or thought. Respectful deliberations are not expected or encouraged. The number of followers one has on Twitter or elsewhere has become the measure of success for some.
For many in a professional sphere, including doctors, email, texting, and instant messaging define workloads and often professional and personal relationships. Electronic medical records (EMRs), where we click boxes of current problems and diagnostic codes instead of writing lengthy and unique details of important clinical observations and findings, have become one of the most time-consuming and cumbersome aspects of physician communications. Conversations with our patients, students, residents, and colleagues have been replaced with typing on electronic keyboards and into our smart phones.
Many physicians have jumped on board with social media, where they can have a variety of professional and personal interactions. But unfortunately, social media sites are often where the conversation is more of a global broadcast between disparate individuals at distant computers using keystrokes, cameras, graphics, microphones, and other multimedia tools. Emails and texts have joined blogs, posts, and tweets as the preferred transmission between individuals, organizations, and institutions. Some are peddling their opinions, positions, wares, and services. Some messages are disguised as important communiques, while information and personal data are gathered, stored, analyzed, and commodified by governments, institutions, or corporations.
As users of digital communications even in the medical sphere, we seem to have lowered our expectations for privacy, security, confidentiality, quality, accuracy and accountability. Somehow even as doctors, we seem to ignore the impact of technology on our minds, attentions spans, opinions, gullibility, reasoning, decision-making, knowledge levels, and communication skills. The comfort and familiarity of face-to-face conversations, as well as other human connections and interactions, may be at risk, never mind our ability to focus on one task or an in-depth endeavor at a time.
We have adapted to the electronic universe even in medicine. Our behavior, our personal interactions, and our expectations for access and processing of information, as well as our communication style, have all been altered at least while we are using digital communications (which now seems like most of the time). Many physicians and patients may even feel more comfortable, confident, and in control when communicating through screens than in person.
There is no doubt that digital communication comes with remarkable speed and the ability to travel across unlimited geographic boundaries, providing access to staggering amounts of data and new ways to locate, analyze, and display those data as never before.
Digital communication in medicine is certainly here to stay, assuming a bigger role in our daily clinical lives and our patients’ lives; patients are reminded to take their medicine by electronic messaging, and they are recording their electrocardiograms with their smart phones and sending us electronic diaries of their moods, blood sugar levels, heart rates, and blood pressures. Patients are Skyping with their doctors. Doctors are using various forms of technology to assess trends in physiologic markers and to predict clinical outcomes.
This chapter will take a closer look at the different methods that physicians, patients, and other medical professionals are using to communicate and interact in social and professional digital electronic spheres.
Today, more than three billion people, almost half of the world’s population, use the Internet. According to Statista, an online statistics market research and business intelligence portal, 77% of Americans have a social media profile, and 2.34 billion people worldwide use social media.1 The reality and perceptions of social media content are unique, unparalleled, and often unaligned. Whether you use Facebook, Twitter, LinkedIn, Reddit, Snapchat, Instagram, blogs, organizational websites, or other online social media sites, you quickly learn that the content is fleeting yet permanent; virtual yet real; private yet public; anonymous yet discoverable—all unusual combinations in the history of communications. This is true particularly regarding physician-to-patient, physician-to-physician, and physician-to-public communications. The number of users of social media is globally pervasive. As of 2018, some of the most popular electronic social media websites in the blogosphere were Facebook (2.23 billion users), YouTube (1.9 billion), WhatsApp (1.5 billion), Facebook Messenger (1.3 billion), WeChat (1.06 billion), Instagram (1.0 billion), Tumblr (23 million), Twitter (67million), Snapchat (186 million), and Pinterest (250 million). LinkedIn reported 500 million users in 2018.2
Social media platforms are the public square where anyone, anywhere with access to the Internet can participate. In this sphere, vast amounts of medical information also exists in the form of health news, clinical instructional videos, physician blogs and tweets, continuing medical education (CME) podcasts, patient support groups, and physician rating sites. Online information from almost every major medical publication, organization, and academic institution is updated daily, hourly, or even by the minute.
Patients often turn to social media for medical information and advice or to find a doctor or a patient support group, and physicians, hospitals, and healthcare organizations have taken note. Half of physician practices (53%) now have a Facebook page.3 Most of the major hospitals have a presence on Facebook and Twitter or other social media sites (Figure 2.2). Of the 5624 hospitals in the United States, 26% participate in social media.4 Of the approximately 1500 hospitals nationwide that have an online presence, Facebook is the most popular social media website—just as it is in the general public.5 After the Mayo Clinic started using social media, its podcast listeners rose by 76,000 according to the Infographics Archive.6
The top ten hospitals on social media include the Mayo Clinic, Cleveland’s MetroHealth System, Baylor Health Care System, Rush University Medical Center, Oregon Health and Science University, Vanderbilt Health, and The Mount Sinai Hospital.7
Today, most hospitals, academic institutions, and professional organizations have special departments and assigned professionals who direct how they use and engage in social media; institutional leaders perceive the benefits for their overall missions and of staying connected to the public. Individual physicians who participate in social media perceive the benefits as “forwarding their career or research endeavors, self-improvement through reading others’ tweets and keeping up with the literature, increasing their reach, (i.e., their audience), and providing a space for them to openly express their opinions,” according to one study by Campbell et al.8 Just as it has in other areas of our society, social media has allowed patients, providers, and institutions to break down traditional barriers to communication and increase the options for, access to, and speed of connections we can make with each other.
Dr. Adam Cifu, Professor of Medicine and general internist at the University of Chicago, is one of the two billion users of social media around the world (Figure 2.3). But he may not seem like your typical Twitter user. Dr. Cifu divides his time between clinical practice, medical education, and scholarly research related to evidence-based medicine. He also has more than 7,788 Twitter followers as of April 2019. For him, Twitter is a helpful tool in his daily professional life.
Tweeting about articles helps me to synthesize and remember them. Tweeting about ideas helps me process them and engage with others for online brainstorming. It also alerts me to articles I would have missed.
—Dr. Adam Cifu
Dr. Cifu is also the author of a textbook and a book for the lay public: Symptoms to Diagnosis: An Evidence-Based Guide and Ending Medical Reversal: Improving Outcomes Saving Lives. He tried to use Twitter twice since 2011, but finally “got it right” in 2015 when he decided to limit his audience to those who were interested in clinical and academic medicine. Like other professionals, he does not necessarily want to hear what someone had for dinner or where they went on vacation; he only wants to discuss issues related to internal medicine. Twitter has introduced Dr. Cifu to “thousands of valuable, virtual colleagues.” Since 2015, he has written thousands of posts. He cannot see giving up his global Twitter audience of professional colleagues, where he averages one hundred posts a month. “Right now, I have incorporated it into my professional life to enough of a degree that giving it up would honestly feel like giving up colleagues,” he says.
Dr. Cifu does not see any downsides to using social media, other than it takes time. He says he leaves his Twitter account open on his desk all day while he is working and seeing patients or going to meetings. It does not interfere with his work and gives him an ongoing connection to like-minded colleagues.
It is a weird society of people who I feel attached to in some way though I am absolutely not attached to because most of them are anonymous. . . . I have no idea who they really are. . . . I am a general internist, my section of internists are about 40 people who are very close colleagues I work with clinically and collaborate academically but that is 40 people of whom 5 are passionate about the same things I am. Here are a couple of thousand people [Twitter followers] who because we have the same interests and talk about the same things on Twitter that usually extends to a much larger group. It is very helpful.
—Dr. Adam Cifu
As the definition and reach of social media continue to evolve, so do the use and potential misuse by organizations and individuals in the profession. With the sheer amount of daily new medical information; the need for accurate point-of-care updates; the public’s appetite for health news; organizations’ pursuit of marketing, branding, fundraising, and self-promotion; and the allure of data analytics, all combined with the speed, function, and expanse of the World Wide Web, we have created either a perfect universe of information or a perfect storm of misinformation—or perhaps both, depending on your point of view.
The term “social media” first appeared in 2004. Since that time, and with the growing electronic universe, the definition continues to evolve. The Oxford English Living Dictionary defines social media as the “websites and applications that enable users to create and share content or to participate in social networking.” The Merriam-Webster Dictionary defines social media as “forms of electronic communication, such as websites for social networking and microblogging, through which users create online communities to share information, ideas, personal messages, and other content such as videos.” Wikipedia uses more than 17,000 words and a bibliography of more than 200 references to define social media.
Physicians use social media for professional networking, clinical education, research collaboration, organizational skills training, patient care, patient engagement and interaction, publicity, and public health promotion, according to medical writer Lee Ventola.9 According to Ventola, more than 90% of physicians use some form of social media for personal activities, whereas only 65% use these sites for professional reasons. Nearly one-third of physicians have reported participating in social networks; and both personal and professional use of social media by physicians is increasing.9
Physicians’ use of the Internet and social media appears to parallel the rest of the population in numbers, with the majority of adults using some form of social media, including Facebook, Twitter, or other applications.
Social media use falls into three broad categories: creation, curation, and consumption, according to, co-founder and Managing Partner of Asentech. Bhaskar believes that very few social media users are actually creating original content, while most are either occasionally commenting on others’ posts or passively viewing what is “published” on the site.10 Bhaskar writes, “Approximately 1% of healthcare professionals using social media are content producers, creating and publishing original content. These physicians are creating blogs, forums, and information-sharing websites that provide information to e-Patients and other healthcare professionals. Another 9% engage with others on social media by commenting on posts and participating in group discussions or online chats. Content curation activities include identifying and sharing useful information or links with followers or other members of an online community. Finally, 90% of physicians are social media consumers. These individuals use the Internet and social media to find and read relevant information related to their patients and practice.”
It is not just access and availability that physicians and patients are interested in, but also accuracy and accountability. They both want evidence-based information, quality research findings, and clinical guidelines from reputable resources.
Physicians use online resources to access medical news and updates, clinical and diagnostic tools, drug databases, and patient information, according to Bhaskar. Physicians have also become accustomed to reading professional and academic journals online, doing CME activities electronically, and accessing clinical points of care from a computer screen on their desktop computer, tablet, or even cell phone. Social media has become the superhighway where some of this data are publicized, reposted, debated, and discussed.
For nearly a decade, most traditional media organizations, including medical publishing organizations and medical institutions, have climbed aboard the social media bandwagon. Most organizations have Facebook and Twitter accounts, including the New York Times, the Cleveland Clinic, and the National Institutes of Health. Even the venerable two-hundred-year-old New England Journal of Medicine (NEJM) has a Facebook page (Figure 2.4). In 2017, the NEJM reached one million followers on Facebook, more than the number of their individual paid subscribers.
“It is important for us to be where our audience is, and social media allows us to do this,” said Jennifer Zeis, Manager of Communications and Media Relations at the NEJM in 2018. Zeis knows that social media works because when the NEJM posts an article or image on social media, it drives readers to the NEJM main website where the original articles and other peer-reviewed primary content have been published. As with other activity on the Internet, social media users can be tracked with “clicks” and “likes,” comments, and other data (Figure 2.5).
The NEJM Executive Editor and Online Editor, Edward W. Campion, who has worked at the NEJM for nearly three decades, believes that using social media is necessary because everyone else is there. Campion says, “I think there is an expectation that you have to have a presence there. If not, then it is ignoring it and there is some opportunity there.” Campion adds, “It gets our name out, it gets out some of the news content, what we are doing and what we are publishing.” But Campion says while this modern form of communication seems necessary in today’s digital world, it is not always easy to know why. “What it achieves from a business point of view I am not sure other than visibility and awareness and some level of engagement,” adds Campion, “you know off the site, those are Facebook users, they are not our subscribers. . . . I think that one effect of social media plays into the whole digital landscape of being always available, 24/7, free and kind of fast and superficial,” Campion concludes.
An Expanding or Contracting Universe?
Social media options for individuals and organizations continue to enlarge, and Twitter has increased its space to 280 characters. (A character on Twitter is defined as a letter, number, punctuation mark, or space.) But most online communication still tends to be very brief. Many individuals, including NEJM Editor Campion, worry about how brief electronic messages, in every form, may be affecting our comprehension, consumption, and retention of in-depth medical articles and scientific information.
An abstract used to be thought of as the short form. But an abstract on the web or social media or email or twitter is too long. People won’t read something that long. It has come down to a shortened version of the title and the web blurb which is two sentences. The attention span is shorter and of course the screens are getting smaller. Most people, especially younger generations are reading on the small screens, on their phones. Ten years ago, that was kind of unthinkable.
—Edward W. Campion
The main benefit of having a social media presence for institutions like the NEJM may be dissemination, marketing, and discussion of their articles in the electronic public sphere. But there are also other advantages when it comes to their global reach to readers. “For us, the main benefit [of social media] is just awareness. A lot of people see what is in the journal. It doesn’t lead to deep engagement. But a broad awareness including an international audience,” according to Campion, “The Journal’s audience is hugely international, and internet and digital delivery and Twitter and Facebook and our million plus people on the email list, allow for more an instant connection with no delay. In the old days, we would send out paper copies that never got there at least in remote places.” Unfortunately, what is often of most interest on social media, is not the lead article or an important ground-breaking clinical finding in the Journal.
It is true that the things that have gone viral on social media have been pretty trivial, Oscar the cat who could sense when someone was dying, the media and social media got onto that. A parasite crawling out of someone’s ear or across an eyeball or something like that are the ones that get a huge amount of attention. It has kind of made for some voyeurism. Social media is part voyeurism.
—Edward W. Campion
So, if social media is largely voyeuristic and it may or may not be prompting individuals to read longer articles or engage in in-depth conversations, what are the tangible benefits and the real purpose? Besides a way to republish articles and drive traffic to an institution’s website, what other purpose does social media serve? Is it really education, collaboration, and discussion, or a place to grab quick bits of data as we need them? Is it often more advertising, marketing, and promotion disguised as information or articles? Is it a way for Facebook or other institutions and individuals to collect, exploit, and monetize our data? For individual physicians, is there any role or specific advantage to using social media—or is it a vast waste of time and distraction with little benefit? What exactly is the signal-to-noise ratio of social media for doctors? Only each individual physician can answer those questions for himself or herself.
The Twitter World of Medicine
If you search for doctors you know or know of, you may be surprised how many are using Twitter. It seems that one of the ultimate goals of having a Twitter account is how many followers you accumulate. As one editorial cartoon by Randy Glasbergen points out in the dialogue between two men: “It is difficult to place a value on my company. Which is worth more, a million shareholders or a million Twitter followers?” The same might be said by physicians with Twitter accounts.
After following and reading various Twitter accounts, you may wonder if there is an inverse relationship between the number of a person’s Twitter followers and the uniqueness, usefulness, and strength of their content, depending on what you are looking for. A wide range of physicians, besides University of Chicago internist Adam Cifu, have Twitter accounts. Here are just a few physicians and the number of Twitter followers each had as of April 2019:
• Dr. Eric Topol, former chairman of cardiovascular medicine at the Cleveland Clinic, now founder and director of the Scripps Translational Science Institute, and awarded a $207 million grant for precision medicine initiative in 2016 (158,000 Twitter followers)
• Dr. Siddhartha Mukherjee, oncologist, writer, and winner of the 2011 Pulitzer Prize for The Emperor of All Maladies: A Biography of Cancer (39,400 Twitter followers)
• Dr. Francis Collins, the director of the National Institutes of Medicine (103,000 Twitter followers)
• Dr. Kevin Pho, primary care doctor in New Hampshire, physician, and author (157,000 Twitter followers)
• Dr. Travis Stork, emergency room doctor and host of television show, The Doctors (169,000 Twitter followers)
In 2017, Twitter expanded its word limit from 140 to 280 characters, but according to Jack Dorsey, CEO of Twitter, the length of the average tweet has not gone up since the character limit change was implemented. The average tweet is about 50 characters—and the average number of words is just 15, not exactly an extensive missive. The most popular activity for physicians on Twitter seems to be tweeting while reposting an article. Unlike traditional media outlets with large staffs who publish numerous articles and original content regularly, many social media users (including physician bloggers and Tweeters) have found that producing original content is challenging, laborious, and time-consuming, and as some in daily journalism would say, next to impossible to continue to “feed the daily news beast.” It is often much easier just to repost someone else’s article and make a quick comment than to write and post your own original material.
Many Twitter doctors engage in a wide range of activities from commenting on an article, cartoon, or image to reposting their own published articles or updates from their institutions. Some physicians post broadcast links to medical conferences or videos or try to engage their audience with a question or political statement. On one day in 2018, Dr. Ashton from ABC News was looking for people who had recently been diagnosed with bronchitis, presumably for her ABC News show. On other days she reposted videos from the Good Morning America television show explaining the new FDA guidelines on e-cigarettes, a new flu strain, and information about superbugs. On another day in 2018, acclaimed author, clinician and researcher Dr. Jerome Groopman reposted an op-ed article by Tom Brokaw written in the New York Times. Dr. Groopman echoed Brokaw’s sentiment and posted his own message, “at a time of rising xenophobia, people with anti-immigrant prejudice should consider that immigrants and their offspring might save their lives.” In September of 2018, Dr. Eric Topol retweeted a NEJM article concerning the association of low-dose aspirin and all cause mortality and then Dr. Groopman retweeted Dr. Topol’s comments as well as his own. Groopman wrote, “Another important finding that argues against coercive quality metrics—every study limitations, and risk/benefit analysis has a subjective core. Better to debate data, honor patient preference and await superior research than top down mandates.” It was a brief medical discussion between two academic clinicians in less than 280 characters. For many physicians, social media has become the way to converse about important ideas, articles, and observations. For others, it is a way to begin an important conversation or “get something off their chest,” or for a way to market themselves or their book, work, research article, or institution.
Dr. Aditi Nerurkar, an integrative medicine specialist, Instructor in Medicine at Harvard Medical School, primary care doctor at Beth Israel Hospital in Boston, and writer, describes her social media use as “a ‘living business card’ for media to find me.” For Dr. Nerurkar and others, social media allows them to update and post their writings, observations, research, and press coverage; Twitter, Facebook, Instagram, Indeed and other online social media venues offer these and other opportunities for physcians who are interested.
Physician-to-Patient Digital Communication
Physicians and healthcare institutions are quickly realizing that social media can be an efficacious way to educate, communicate with, and attract patients. Patients use social media to find medical information and advice, hospitals and providers, and even other patients. There are myriad ways institutions are captivating and educating patients through social media.
Dr. Joseph Dearani, Chair of the Department of Cardiovascular Surgery at the Mayo Clinic, specializes in the repair of pediatric and adult congenital heart surgery, including Ebstein’s anomaly. He has created a Facebook page for patients so that they not only can watch a video about cardiac problems and therapeutic procedures but also can hear about, and meet, other families who have been through similar problems and interventions. Facebook helps him and his department inform patients and families before he meets them in person. According to Lee Aase, director of the Mayo Clinic Social Media Network, the electronic consumer space of Facebook and other social media sites “are not replacements for a visit with the doctor,” but, if used properly, can be “effective tools to educate and engage patients.” By the time that patients and their families meet with the doctor, they may feel like they know the doctor from watching a video presentation. They may understand more about their diagnosis from watching the diagrams, explanations, and patients discussing their treatment on the website. The online information may prompt patients and their families to formulate their questions and concerns before their first visit; and it may make the exchange of information in the face-to-face meeting easier and more productive.
The Mayo Clinic has also used Facebook and other social media sites in various ways to promote public health programs and increase awareness about important health issues such as colonoscopy and other health screenings. The Mayo Clinic has produced programs such as a “live stream” colonoscopy to promote screening colonoscopies. The Mayo Clinic’s transplantation center posts blogs to educate the public about living organ donation and helps connect potential living donors and recipients (Figure 2.6).
Social media platforms and other online medical information can help patients understand their condition and be more involved with their treatment; overall, it encourages patients to play a more active role in their healthcare. But according to Ivan De Martino in an article published in the Current Review of Musculoskeletal Medicine in 2017, “In this way, patients are not passive consumers of health information.” But he warns that the electronic medium is not without risks: “it is difficult to control or regulate the sources and their quality, and bad or misleading information can be detrimental for patients as well as influence their confidence on physicians and their mutual relationship.”11
Clearly, the institutions, professional organizations, and individuals engaging with social media directly determine the quality of the content they post. The problem comes when patients are searching for important or even life-saving information and don’t know how to find reputable sources or recognize established and credible organizations. Just like with all information online, there are broad-ranging concerns about quality, authenticity, and accountability of medical information online. In 2018, Facebook deleted 583 million fake accounts, more than 25% of the 2.2 million monthly active users. How can patients or anyone be certain that what they are seeing or reading online is true or is actually from the person or institution supposedly behind the post?
Risks of Social Media
User-generated content by physicians or any other social media users, such as text posts, comments, articles, photos, videos, and online interactions, are the “lifeblood of social media”; however, any information on any social media platform is not without risks. “There are concerns about the security, privacy, and confidentiality of the personal health-related information shared on these social platforms; the quality and accuracy of the information shared; and the credibility of the individuals who post medical advices and tips,” writes Ivan De Martino. Professional organizations and other institutions have begun to develop guidelines for healthcare professionals regarding social media. (There is a list of guidelines at the end of this chapter and a list of resources concerning social media and digital communications.)
While social media sites can promote individual and public health, as well as professional development and advancement, according to Ventola, “when used negligently, the privacy and security risks concerning health care information are very real.” That is why, if you engage in social media, it is critical to stay up to date on the guidelines provided by medical-legal professionals, healthcare organizations, medical societies, and others to help you avoid problems.
Social Media and Medical Conferences
Each year, there seem to be new communication uses for social media. There is an increased growth and rapid use of Twitter, Facebook, and other platforms by healthcare providers attending medical conferences who want to communicate with their colleagues, patients, and the public. According to hematologist-oncologist Dr. Naveen Pemmaraju of MD Anderson Cancer Center, there is a growing amount of research in this area demonstrating an increasing interest among physicians on how to use social media for consumption of educational material and how to generate and contribute original content based on one’s interests and expertise. It is not uncommon for physicians sitting at medical conferences to update their Twitter posts from their laptops and Facebook pages from their cell phones.
Dr. Pemmaraju writes, “Hematologists/oncologists are engaging regularly in one of the most common forms of social media, Twitter, during major medical conferences, for purposes of debate, discussion, and real-time evaluation of the data being presented.”12
Providing the ability to communicate real-time updates and information from conferences helps physicians inform and engage colleagues and the public. It also may serve as a “note-taking service” for the physicians themselves while they are busy posting and commenting on the information presented at the meeting in real time. They may field questions, initiate discussions, and post comments from their colleagues who are not physically in attendance at the medical conference.
In this way, the information presented at medical conferences is disseminated and publicized to a much broader audience at no added expense by the conference organizers. Yet there may be a loss of registration fees or control for conference administrators, since many who did not pay to attend the conference may be gaining immediate access to some of the information presented. For some conference organizers, it may be a win-lose situation: they are gaining publicity but losing attendance rates and some sense of command over their content distribution. But many medical conferences now charge for “electronic attendance” or access to full online video recordings after the conference and run their own blogs and posted discussions. Conferences are also upping their technology games by using live interactive polling and other electronic devices to keep their audiences engaged.
The online physician ratings posted by patients are often one-way directed online messaging from anonymous individuals and hosted by organizational platforms. Much has been written about the pros and cons of online physician reviews. Many physicians are all too familiar with the sting of a negative online comment from an anonymous patient. Some sites allow for physicians to contest or respond to negative reviews and sometimes have them removed. Organizations can also offer advice on ways to respond to patient reviews, encourage patients to leave positive reviews, and help you improve your ratings. Many private companies and consultants now promise physicians and organizations help in managing their online reputations.
Regardless of the accuracy and authenticity of online physician reviews and ratings, patients still respond to them. One study by Carbonell published in 2018 in Health Communication found that patients’ decisions about selecting a provider were influenced by online ratings—and the higher the number of users the more influence the social media cue had on patients’ behavior in selecting and seeing a particular physician.13
We found that the participants’ likelihood to visit a physician varied with respect to the displayed physician characteristics on the platform. Importantly, after the recommendation of others was presented, participants’ likelihood to visit the physician changed significantly. The participants’ adjusted response was significantly closer to the recommendation coming from a higher number of users, which indicate that this online, social media cue influences our decision to visit physicians.
Often, physicians will be more likely to receive positive online ratings for individual skills such as competence, likeability, and character. Negative ratings are more likely to be related to their office staff interactions, billing, and office environment, according to an observational study by Chester J. Donnally III in 2018.14 Apparently, a social media presence on Facebook, Twitter, and Instagram increases the number of ratings and comments, but not overall scores on physician review websites. “Understanding the factors that optimize a patient’s overall experience with a physician is an important and emerging outcome measure for the future of patient-centered health care,” according to Donnally.
Physicians and Patients: Uses of Social Media
a. Physician to physician
b. Physician to patient; patient to patient (virtual health communities; MDTALKS.com)
c. Physician to the public
a. Physician to physician/resident/student
b. Physician to patient/the public
a. Physician to physician (clinical information)
b. Physician researcher to researcher
c. Clinical researcher to patient
a. Physician self-promotion
b. Organizational promotion
c. Issue promotion/disease awareness
d. Public health information dissemination
The social networks Sermo www.sermo.com and Doximity www.doximity.com are examples of physician-only social networking communities. They allow physicians to discuss topics ranging from reimbursement and board recertification to patient care and personal issues. Other online social networks for doctors include DailyRounds www.dailyrounds.org; QuantiaMD www.quantiamd.com; Among Doctors www.amoungdoctors.com; Figure1 www.Figure1.com; Incision Academy www.incision.care; Student Doctors Network www.studentdoctor.net; MomMD www.mommd.com; and Doctor’s Choice www.doctorschoiceusa.com. The website communities promise to offer professional connections, crowdsourcing, career and personal advice, and other educational and professional resources. Some allow for use of pseudonyms for anonymity. Many promise protection of information and offer text and images that are compliant with the Health Insurance Portability and Accountability Act (HIPAA). Physicians are also using “private” or organizational social media sites for point-of-care information as well as for discussions of various clinical conundrums, research topics, and professional collaborations.
I signed up for a physician-only social network and shortly began receiving regular email invitations to take surveys for which I would be paid $25 to $80. To participate in any of the surveys, you first have to answer a number of questions about yourself and your practice before they determine whether you qualify to take the survey questions. As many of us now know, our data are now a major commodity. Perhaps there are various ways, besides traditional electronic advertising, that some of these websites are funding their enterprises.
Electronic support groups are popular for physicians, just as they are for patients. Physician Moms Group https://mypmg.com was founded in November 2014 by Dr. Hala Sabry. Today, more than 71,000 physicians of all specialties share, collaborate, and support each other in this open forum. Various topics are shared and discussed, including financial, medical, career, family, child-raising, and relationship advice. A colleague of mine from medical school uses Physician Moms Group daily through Facebook and says that reading the stories of other women physicians’ lives and their stresses is supportive, collaborative, and “a fantastic way to support other women physicians who are moms.”
As more physicians participate in various social media opportunities, and even the NEJM has a Facebook page and a Twitter account, the Mayo Clinic has developed a social media department of education and physician networking. The Mayo Clinic Social Media Network (MCSMN) provides training and certification in social media for physicians and is a “global community for those interested in advancing health-related application of social media tools.” It seems that you can essentially complete a residency in social media training now if you want to.
Online Information and Social Media Summary
Our participation in social media and other aspects of the digital world in general may have altered the way we behave, interact, and communicate and even process, learn, analyze, and recall information. But how has it changed our relationship with patients, students, residents, and peers? Consider how texting between residents and attendings may have altered the way residents present patients, transfer patients, and learn how to provide care. Think about how the EMR has affected both physicians and patients, from face-to-face communications to age-old doctors’ notes about the social and medical histories, physical exams, and treatment plans of their patients. Think about how we access point-of-care information and guidelines with a computer instead of with each other. There is not an area of medical care or medical education untouched by the digital age.
I remember when, several years ago, I first heard medical students or residents presenting information that they said they “found online.” I and others would gently but quickly urge them to reference the primary literature: the academic journal or organization where the information originated. Physicians-in-training, as well as physicians-in-practice, need to know how to reference information and to evaluate and question it, especially when it comes to making important clinical decisions. The fear is that, with the abundance of information online with sometimes questionable origins or validity, even physicians may become unfamiliar or unable to discern the authenticity, authorship, transparency, or even the quality of the knowledge they obtain online.
As more physicians use digital tools, additional guidelines become necessary. There is an ever-increasing need for academic leaders, medical organizations, and professional societies to offer institutional support, instruction, standards, and recommendations for online medical information and exchange, regardless of whether physicians are using the Internet to access clinical information, market themselves and their services, inform and educate trainees, communicate with patients, discuss difficult cases with colleagues, monitor employees, provide accurate information and encouragement for patients, or express opinions about the latest healthcare controversies. According to the Massachusetts Medical Society, “Carefully planned and professionally executed participation in social media by physicians is professionally appropriate and can be an effective method to . . . enhance the public profile and reputation of our profession.” But we may need more guidelines and support than what is currently provided by medical societies, the American Medication Association, Food and Drug Administration, Federal Communications Commission, and laws like HIPAA to ensure that online medical information is accurate, transparent, and authentic and that personal health information is protected.
At a time when patients expect, if not demand, our digital participation, they continue to search for online medical information and post questions, share experiences, and try to connect with other patients and providers. About six out of ten Americans search for health information online, according to the Pew Research Center.15 The most accessed online resources for health-related information among the public are as follows: 56% searched WebMD, 31% Wikipedia, and 29% health magazine websites; 17% used Facebook, 15% used YouTube, 13% used a blog or multiple blogs, 12% used patient communities, 6% used Twitter, and 27% used none of the above according to the digital media company Mashable.6 When the public is asked about their trust in various sources of online information, information from healthcare providers is ranked highest for trust in accuracy. Online information from family and friends and information from local public libraries ranked second and third as “most trustworthy” according to a survey by the Pew Research Center.
Interestingly, 60% of doctors believe that social media improves the quality of care delivered to patients.16 Increased collaboration among physicians and empowerment and education of the public are some of the hopeful aspects and potential advantages of social media. According to Dr. Eric Topol, cardiologist and digital medicine researcher, access to medical information by patients, at the very least, helps diminish paternalism in the profession.17 Empowering patients with knowledge is an excellent motive for improving the accuracy and accessibility of online information. But if, in fact, social media has given both patients and physicians more power through new tools and new access, we must hope that it can also improve care somehow through efficiency and responsiveness. That can only occur if we can keep a close eye on who is providing the online information, the accuracy of the information, how digital communications affect us as care providers, and most important, how social media affects the patients we provide care for.
As younger physicians who are more adept with electronic communications replace older physicians who are “non-native” digital communicators, the online world continues to expand into the practice and the profession of medicine. Digital medicine in one form or another appears to be increasingly integrated into our healthcare system. As Swati Bhaskar writes:
With an increased use of digital medical records, personal virtual assistants, and wearable devices, we expect to see new and innovative ways for physicians and patients to interact through social media in the years to come. As this growth continues, new platforms and apps will develop to facilitate interactions and help more physicians become active social media participants.
Of course, new technologies, including digital networks, have the potential to change our communication and our human relationships inside and outside of the hospital. According to Robert Wachter, “part of the work of getting technology to achieve its potential—overcoming the productivity paradox—is to think about these relationships, to be honest about which losses are survivable and which are not, and to build in fixes that recreate (or reimagine) the parts of the exchanges that remain crucial to the work.”18 As more of us (and our patients) become social media users, the playing field of health information exchange, knowledge, and accessibility continues to change—as do our relationships with and care of our patients. We have to remember that, at best, social media enable and encourage conversations. “The expectation is that others will talk back and you will listen,” according to Daniel Goldman, in Bringing the Social Media Revolution to Health Care.19
The problem with online forums of information for security and privacy risks cannot be overstated. Nor can the questionable sources, authorship, conflicts, and motives. But as the information regards symptoms, diagnosis, prevention, treatment, and other medical advice and opinion, we should remember that people’s personal information, their health, and their lives are at stake. Whether it is a physician, a patient, or an organization posting, discussing, and imparting information and guidance, there may be large audiences, such as patients and physicians, who are reading and responding. Individuals are potentially making important decisions, such as changing their medical decisions, personal lifestyle choices, and even medication dosages, based on the online information they consume.
Interwoven into any discussion of electronic communications is the problem with the loss of human-to-human connection and personal communications. What happens to our eye-to-eye contact, our empathy and understanding, our healing touch, and other provider–patient connections, all vital to patient care, in this world of online medicine and medical information? As we grasp the realities of the online universe we now live and work in, we are not alone in our fears and our lack of knowledge about the impact of this technology on many aspects of our lives, including our physician–patient interactions. We might benefit from listening to colleagues from other professions for guidance.
Reverend Rebecca Spencer, Senior Minister of the Central Congregational Church in Providence, Rhode Island, can be inundated by the demands of the online world, but she strongly believes in the importance of the ministry of presence. To do this, she says all of us, including ministers and doctors, need time and an absence of computer screens. She remembers that when her husband was dying, they were most helped and moved by the caregivers who listened the best—and that was not always the doctors. But she says small gestures made an enormous impact—small gestures of listening and caring in the clinic were greatly welcomed and appreciated by her and her husband. Digital communication does not allow for human gestures that may touch the heart and heal the soul.
Dealing with the electronic world is not always easy for Baptist Pastor Edward Bolen in Athens, Georgia, who wrote the following:
My teenage children tell me that Facebook is for old people now; they much prefer Snapchat, Instagram, and Twitter. I’m bombarded with folks who want to connect with me through LinkedIn or share articles via Reddit or StumbleUpon. The pace of technological innovation and the growing access through portable devices pose a double challenge for clergy.
First, there is the pressure to use an assortment of new communication tools while maintaining proficiency with established skills. Second, there is the stress of finding the time to answer emails, return calls, respond to texts, schedule appointments and visits and reply to Facebook comments. Yet we are being given unprecedented opportunities to reach, share, network and cooperate with members of our congregation and to be part of a growing Christian community beyond the walls of our local congregation. How do we manage these challenges?
—Pastor Edward Bolan
We as physicians face the same challenges—whether its figuring out when to check email, when to finish typing electronic charts, and when we need to turn off our devices altogether. Pastor Bolen’s advice may be relevant for all of us bombarded and sometimes baffled by the pervasiveness of electronic communications:
Placing boundaries—even daily limits—on phone calls, email and technology allows for the opportunity to accomplish other tasks and to have a reprieve from the constancy of communication. The disciplines of stopping and organizing are essential skills if we are going to manage productively the information and technology surrounding us.
—Pastor Edward Bolen
There is no doubt that social media changes the way most people communicate and connect with friends, colleagues, and the public. And no one can predict how it will continue to affect patients and physicians. The next iteration of social media and how it might be adapted by those in clinical medicine and medical education or continually affect healthcare, therapeutic relationships, and medical information exchange is anyone’s guess.
We know that communicating machine to machine over long distances filled with electrons and without the privacy and intimacy of the exam room is different and fraught with legal, ethical, and professional worries. Social media may be out of our normal professional bounds and often out of our comfort zones because it does not include the bedside discussions with patients or the traditional private interactions with colleagues or professional presentations to academic audiences that we are used to. But this virtual universe of electronic information exchange is a fact of life, and we will continue to wrestle with it for the rest of our lives.
As more “professional” social media options become available, more people appear to be willing to trade their privacy for online global and immediate connectivity. This includes patients and physicians. But are the lessons for improving our communication skills different when we enter this novel medium? It seems that we are discovering this as we learn to ride the daily digital tsunami.
Structure and transparency in social media are often absent, unlike traditional media, where authorship, editing, peer review, disclosure of conflicts of interest, and established protocol and publishing guidelines are still more likely to prevail. While the context, intent, and origins of some social media messaging may be difficult to discern, the public seems to be more on the alert and questioning of social media missives. With the knowledge gained after publicity surrounding scams, hacks, and worse, many now realize that the capabilities and culpabilities of the creators of online information are largely based on the acceptance, interpretation, and ultimate use of the information by the public—or in the world of medicine, on the behavior of patients and physicians.
So how does a centuries-old profession, which still relies on a listening ear and human hands to heal the sick, begin to adopt, adapt, and best utilize digital communications? No one can predict exactly how the electronic age will continue to affect the practice of medicine, the education of physicians, or the health literacy and behavior of the public. As we all ride this virtual highway of electronic data, where billions of others surf, drive, and connect daily, physicians, like everyone else, need to find the best roadmap to help ensure accuracy, accountability, privacy, and reliability both for our patients and for our profession.
Advice for Using Social Media
1. Decide why you should (or should not) use social media professionally and personally.
2. Review the benefits and risks of social media and discuss with trusted colleagues who have experience in this area.
3. Ask your employer, hospital, state board, or professional organization for their social media policy and follow it. (If they do not have one and you have expertise in this area, help them draft one.)
4. Separate personal and professional content online.
5. Do not violate HIPAA laws and reveal any identifiable personal patient information, or else you may face civil, criminal, or professional penalties.
6. Consider taking a course about social media or hiring someone or an organization to help you.
7. Use privacy settings to safeguard personal information and content. (If you don’t know how to do this, ask for help.)
8. Routinely monitor your Internet presence and make sure your personal and professional information is accurate and appropriate. You can directly contact and appeal to websites or obtain professional help if necessary to remove negative or inappropriate content.
9. Follow existing professional codes of ethics for physicians when taking part in social media and communicating in online communities. Assume that whatever you write or post can be seen by all—and will be permanent.
10. Pause before posting and think before sending. Protect your patients and their privacy. Protect yourself and your reputation. Always adhere to your professional standards and responsibilities, whatever medium you are using to communicate.
Electronic Medical Records
For many physicians, there may be no greater impact on communications with patients than the EMR. More than 80% of doctors in the United States now use EMRs.20,21 While much has been written about electronic medical records and their advantages, including quick and reliable access to all clinical information and data, improved legibility and efficiency, ease of locating and sharing information with physicians and patients, graphing trends for patient data, and increased efficiency of communication between different caregivers, the intrusion of a computer into the room where we see patients has been difficult. The disadvantages of EMRs include that it is time-consuming to type in data for some clinicians (systems are sometimes difficult to learn for older doctors), inaccurate information can be pasted into the medical chart, and typing data into the EMR has become a barrier between doctor and patient. There may be no better way to understand the impact of the EMR than to compare old patient charts with new ones: whether in psychiatry or cardiology or orthopedics, the differences are startling. Read a chart from 10 or 20 or more years ago, and you will see how our charting, language, discussions, and recorded medical information have changed. But you may also see that when it comes to information like immunizations, medication allergies, radiology images and demographics, and medical history, we have become attuned to how an electronic system can be advantageous. But like any record, electronic or not, the information is only as good as the person entering it into the record.
How the EMR affects your physician–patient communications is just as important as how it affects the care of your patient. The next time you provide training on your electronic charting program, ask your team how they are making sure that the computer is not interrupting their relationships and care of their patients. The next time that you take a communications training course, ask the teacher for advice on how to limit the negative impacts of the computer on the care of your patient.
How to Prevent the Computer from Interrupting Your Care
• Try to chart outside of the exam room if possible.
• If you must type in front of your patient, limit the time you spend on the computer.
• Make sure the computer is not physically between you and your patient.
• See if you can use a WiFi-connected laptop computer on a mobile high-topped table that you can wheel from room to room while you stand near your patients and push the table away when you don’t need it.
• Show the screen to your patient and describe what you are doing.
• Show the patient their information (x-rays or lab results) on the computer.
• Make more eye contact with the patient than with the computer screen.
• During the patient’s questions, discussions, and your closure, make sure you are not looking at the computer, and the computer is closed and turned off.
While it is true that in the past, paper charts could be difficult to locate or at times completely lost and sometimes were illegible or incomplete, written medical notes, when done well, were a personal expression of physicians’ assessment, diagnosis, and recommendations for the care of their patients. But it is unrealistic in this electronic information age to think that we would ever go back to paper charting. For now, it appears we will just have to continue to think of ways to prevent the EMR from interrupting our communications and care of our patients.
Email: Management, Etiquette, and Professional Guidelines
It used to be that if you had a question or concern for your doctor, you called the doctor’s office. You either spoke with a nurse or your doctor to obtain an answer and advice. But more patients want to email or text with their physicians. And more physicians are using email, texting, and other electronic portals to communicate with their patients. At some point email communication between doctors and patients may become as common as telephone calls or even in-person office visits. The benefits of this electronic communication include an efficient exchange of information between visits with your patients. But there are risks, downsides, and specific medical-legal policies regarding email communication that you should know.
With the average person receiving more than one hundred emails per day, the last thing most people, including physicians, need is more emails. However, physicians cite the following advantages of emailing with their patients, as well as using cell phone calls and text messaging: improved relationships with patients; saving time; and better follow-up care. The main disadvantages include misuse by the patient, interference with private life, and lack of reimbursement. Of course, one of the biggest concerns is protecting private health information.
The decision about how, or even if, you are going to use email to communicate with patients may rest solely with you. Your employer, institution, medical society, colleagues, legal advisor, or staff may offer their input, but ultimately the decision will be yours to make. If you do decide to email with patients after reviewing the pros and cons, then you may want to develop a specific set of policies and guidelines to inform both your patients and your staff.
Your written policy regarding electronic communication with patients should include rules that clarify appropriate and inappropriate topics and how best to use email. You may also want to obtain signed agreements by your patients regarding communicating protected health information (PHI) through secure, encrypted, or public unencrypted electronic systems that are not secure. You will want to specify when and how you will respond to emails and make sure your patients have an appropriate understanding and expectations for the role of email communications with you.
Efficient or Overwhelming?
For most professionals, including physicians, email has become a twenty-first-century communication necessity. Invented in the 1960s but with limited technology support until the 1990s, the sheer number of emails produced today illustrates the explosive popularity of constant Internet missives and communiques five decades after the idea was first conceived. Worldwide, some 269 billion emails are sent each day among 3.7 billion email users. The average email user receives more than three thousand emails each month and thirty-six thousand emails every year.
While texting and instant messaging may have an increased presence in our regular electronic communications, for many, if not most, it is traditional email that defines our day and our work as well as our human correspondence. Unfortunately, email clogging up our overwhelmed inboxes can be yet another major obstacle in a sea of electronic distractions that disrupts workflow and decreases productivity for many physicians and others. Email is also an area rife with potential problems for miscommunication, misinterpretation, and missed messages or opportunities. The unforeseeable missteps are many: not seeing or reading an email, not answering quickly enough, making an ill-received attempt at humor, putting an expression in ALL CAPS or with explanation points (that some perceive as yelling), misspelling someone’s name, using the wrong greeting or closing, using too many or too few words, and many other false steps.
Learning how to better manage our email communication in all areas of our professional and personal lives can mean improved output and information exchange as well as smoother, more successful lives in general. Of course, the basic rules of good communication do not change with different methods or modes of technology, including email, but additional guideposts need to be established and applied; being professional, courteous, respectful, efficient, and responsive and using common sense should be understood by all. However, the unspoken rules and idiosyncratic behavior of different individuals regarding reading, writing, and sending email seem to have arisen organically as the technology has permeated our world. We have taught each other what we like and dislike but often not without bumps in the road for personal relationships or professional exchanges.
What some people seem to have forgotten is that emails are permanent, public, and discoverable. Emails can be monitored and recovered. Work or institutional email is not private. Employers are free to monitor these communications as long as there is a valid business purpose for doing so. We have come to understand that personal emails are essentially not private. When legal issues have arisen around email, the courts have ruled in some cases that a search warrant was necessary to recover and retain certain emails, and in other cases search warrants were deemed unnecessary. It appears that institutions, including the government and corporations, can obtain access to our emails and can read, survey, and save them with or without permission in some instances.
According to the American Management Association, more than 50% of companies monitor employee emails, and many of these companies have reprimanded or fired employees for misusing email. Privacy lawsuits regarding email content have exponentially increased in number. Lawsuits arise from emails containing offensive material and often from attempts at making “innocent” jokes that are later deemed racist, sexist, libelous, or defamatory. Email can be admitted as documentary evidence in court, and specific federal and state privacy laws regarding email differ. The courts have sided with the employer or institution accessing a person’s email or with the employee whose emails were read, depending on the circumstances.
The First Amendment (freedom of speech) and Fourth Amendment (right to privacy and security of individuals against arbitrary invasions by government officials) to the US Constitution can apply to emails, texts and other electronic communication. In 2010, the US Circuit Court of Appeals sided with an employee saying that government agents violated his Fourth Amendment rights when they accessed his emails without first obtaining a search warrant (United States v. Steven Warshak et al.). The case is notable because it is the first case from the US Circuit Court of Appeals to explicitly hold that there is a reasonable expectation of privacy in the content of emails stored on third-party servers and that the content of email is subject to protection by the Fourth Amendment. However, in a case decided by the US Supreme Court in 2010 (City of Ontario, California v. Quon), the court sided with the employer (a police department taking disciplinary actions against two police officers following an audit of text messages they sent on their pagers that were found to be personal and sexually explicit). The judges ruled that examination of the employee’s text messages on a government-issued pager did not violate the Fourth Amendment.
Of interest, where and when the electronic data are stored and who owns the electronic systems holding the data has mostly determined who has legal access to emails and other electronic data. The Stored Communications Act (SCA) of the Electronic Communications Privacy Act of 1986 distinguished between electronic communication services whose only role was to archive and back up transmitted data and systems transmitting or receiving data. Systems or services that actively transmit and receive data can release transmitted data only to the sender or recipient; however, remote services whose only role is to archive or back up transmitted data can release that information to the subscriber regardless of who had sent or received the electronic communication. Of note, in 2018, the CLOUD Act (Clarifying Lawful Overseas Use of Data Act) was passed in the United States. The law contains a provision requiring all email service providers to disclose emails within their “possession, custody or control” when deemed necessary even when those emails are located outside the United States according to Amy Howe writing at scotusblog.com.
Whether you are a politician, public figure, or physician, emails, texts, and other electronic communications are not without risks. Regardless of the nature, context, or ownership of the email, you could be potentially liable. For instance, if what you are writing is determined to be harmful to an employee’s or colleague’s reputation, it could be considered defamatory in certain situations. Regarding emails, attorney Michelle Fabio writes, “As the age-old saying goes, ‘think before you speak’ or in today’s lingo, think before you send.”
Clearly, when it comes to email, knowing that email can be considered a public record if its content contains the transaction of public business and that, legally or illegally, emails can be copied, published, recorded, edited, forwarded, misread, misinterpreted, and misused, as well as appear inadvertently in the wrong recipient’s inbox or on the front page of the newspaper, may help reinforce the need for individuals to be careful, cautious, and constitutional regarding these ubiquitous electronic exchanges.
One of the biggest downfalls of email seems to be time consumption. Awareness is the first step toward time management of emails. It is important to be aware of your email style and behavior. How often do you check email? How and when do you respond? How often do you delete emails and should you delete them? We all differ, but like all behavior, knowing your own habits and style and learning some professional skills to manage and improve your communication clarity, productivity, vulnerability, and efficiency can be important.
You can decrease your frustration and increase your efficiency by learning how best to utilize your email system.
Organize, Categorize, and Prioritize Your Email
• Organize emails into topics.
• Mark for later action.
• Set up electronic folders.
• Consider setting up separate email accounts.
• Utilize settings to filter out promotions or block spam
You may want to take advantage of different ways to organize emails into topics, mark them for later action, use electronic folders, and consider the pros and cons of having more than one email account. Whether you are someone who doesn’t mind having 50,000 emails in your inbox or someone who deletes and organizes emails daily, there are many ways to help you organize and manage the barrage of content and information you now receive daily. It may require knowledge, practice, and time, but like all organizational techniques, it can save time and offer other benefits in the end.
Getting a handle on your email can help determine how productive you, your colleagues, and your staff will be. One method that seems counterintuitive is to set up separate email accounts. This method helps you divide business from personal communications, avoid promotional marketing materials, and be more useful and responsive when handling different activities. Whether you are communicating with colleagues or employees or making reservations, buying insurance, or organizing a family vacation, separate email accounts can help you manage your electronic communications. More than one email account can help you organize different jobs, people, projects, and teams.
Advantages of More than One Email Account
• Separate business from personal communications.
• Organize different jobs, activities, or projects into different email accounts.
• Help avoid promotional marketing materials by using separate email for purchases, reservations, and other online ordering.
• Limit the amount of email to each account.
• Limit the time you have to check each account.
• Set up one exclusive email account (encrypted if possible) for patients.
On average, people today have just less than two email accounts each; some people, of course, have more than two. I spoke with one person who set up a few of his own domains so that in total he had about 40 separate email accounts in the past 15 years. But that is an extreme example—most people have a primary email account they check much more often and one or two other email accounts they check less often. Others might set up one email for their finances or investments, and another for a research paper or specific project they are working on with many other people.
Our email communication, from how quickly we respond to exactly how we write and construct our messages, represents our personal style, character, and image we present to the outside world. Similar to our other professional habits, including our appearance, handshake, voice, signature, and attire, email etiquette and responsiveness can be a reflection of not only how we communicate but who we are.
There are ways we can improve the style and efficiency of dealing with this deluge of transmissions.
Advice for Improving Email Efficiency
• Check email only during specific times throughout the day.
• Monitor your time spent on email (be aware and set your own limits).
• Use the delete button daily (delete trash weekly or see next bullet).
• Install an automatic archive system if there is any personal, business, or legal reason that you want to save your emails.
• Consider setting up separate email accounts for different parts of your life.
• Create folders (for specific topics or projects).
• Learn how to mark or star for later action or to categorize.
• Learn how to highlight or flag for waiting, reference, or archive.
• Resend to yourself for a date you want to take action.
• Turn off audio or visual alerts (unless you find these helpful and not distracting).
• Advise colleagues on your style and use of email communication (when and how you read and respond as well as what you expect from them).
Emails require various levels of decision-making. Most would agree to open them and deal with or delete them as soon as you can. Author Sally McGhee recommends using “the four Ds for decision-making” instrumental in other areas of our professional lives: deal with it, delete it, delegate it, and/or defer it. This strategy can be particularly beneficial when applied to our daily expanding email inboxes.
The bottom line is that once you set a time to look, open, and read your email, you should have a plan of what you want to do and how to proceed. You should not close an email until you have taken an action and either dealt with, deleted, delegated, or deferred it or put it in a folder, forwarded it, or marked it for future action.
Our communication skills, even in a brief email, are on full and permanent display once we hit the “send” button. Our grammar and syntax, as well as our professionalism and protocol, make an impression on the recipient and reflect back on us whether we realize it or not. The tone of our writing, our attempts at humor, the lack of use of a greeting, the closing or subject line, or a mistaken keystroke, missing word, or sentence may inadvertently be misread and muddle our message and mislead the recipient. Most of us have had at least one or more messages go awry. Reviewing some basic rules to put your best “email foot” forward may help eliminate those.
Advice for Writing Emails
• Use appropriate greetings (e.g., Dear [name], Dear Sir or Madame, Hi there).
• Use appropriate closings (e.g., Sincerely, Warmly, Regards, Thank you, Cheers, Best).
• Be brief (one to two paragraphs at most).
• Refrain from “reply to all” and limit cc/bcc use unless it is necessary.
• Avoid use of BOLD or ALL CAPS or all small case.
• Watch tone.
• Be careful with humor.
• Never assume your intent will be automatically understood.
• Check grammar, spelling, and punctuation—be your own editor.
• Spell the recipient’s name correctly.
• Check recipient’s email address before hitting send.
• Check the accuracy of the subject box.
• Avoid large attachments.
• Read thoroughly first before sending.
Advice for Receiving and Responding to Emails
• Open quickly.
• Respond promptly.
• Confirm receipt.
• Let sender know when they can expect response if not responding right away.
• Never assume the sender’s intent of an email you receive.
• Update subject line.
• Avoid hitting “reply to all” unless absolutely necessary.
• Pick up the phone if a more personal, lengthy, or detailed response is needed.
There are some common questions I often hear regarding email. They primarily involve difficult or emotional situations. When the topic of an email is potent or potentially fraught with critical or sensitive material, or the relationship between the sender and the recipient is strained, or their emotions are heightened or conflicted, what is the best way to proceed? After all, not all emails are a simple and quick exchange of information free of emotion, unwritten meaning, or backstory. Email can be easily misinterpreted and cause misunderstandings similar to all communication between humans.
1. When is it okay to ask to be removed from email lists?
If the content is not relevant to you or certainly of interest to you, then it is fine to send out an email request to be removed from an email list. You can ask in a courteous, professional, and succinct way. You can also invite an individual on the list to keep you apprised and notify you if the information becomes relevant to you again or they need you in the future.
2. When is it okay not to respond to an email?
Similar to other areas of your life, using your best judgment can sometimes help you answer your own dilemmas. Why do you not want to respond? How is no response likely to be received? Think back when you sent an email and did not receive a response—if you were expecting one, how did you feel and eventually respond? If an email goes unanswered, then the sender is left to wonder if her email was ever received or if the recipient has another reason for not responding. Depending on the topic, the people involved, and all the different ways you may want to handle it, you can always ask a trusted colleague and look to yourself as the best judge on how to proceed. Waiting 24 hours or more and after a good night’s sleep to decide how or when to decide to respond to an email can help provide clarity as well. Picking up the phone to respond or seeking out the person for a face-to-face meeting may be the best response of all.
3. What should I do when sending an emotionally charged email or an email that concerns a very important matter?
First, remember that email is not always (or perhaps ever) the best way to communicate. Consider all the other ways you might communicate best about the issue. If you must send an emotionally charged message by email, type it in Microsoft Word or other word processing application, save it, and then read aloud before you type it, or cut and paste it, into your email to send. You might also first consider sending the email to yourself, then you can see what it feels like to receive, open, and read it as you have written it. If you can, wait a day or two to think about it, then read it once more to yourself before you finally send it.
Exchanging Emails with Patients
What is your current policy with regard to email exchange with patients? What should it be? What are the guidelines from your institution or your medical association? Is it possible to avoid emailing patients when we now live in a world where electronic communication has pervaded all facets of our professional and personal lives? Would it save you and the patient time to utilize email in an efficient, effective, and safe way?
In a survey conducted by Johns Hopkins Bloomberg School of Public Health published in 2016, 37% of patients reported contacting their physicians by email within the last six months, and 18% by Facebook. However, emailing with patients for many physicians still feels awkward at best and unprofessional or even illegal with regard to HIPAA at worst. How do physicians who exchange emails with their patients offer quality communication and care and at the same time protect their patients and themselves from problems?
The following guidelines are from the US Department of Health and Human Services website regarding exchanging emails between physicians and patients:
The Privacy Rule allows covered health care providers to communicate electronically, such as through e-mail, with their patients, provided they apply reasonable safeguards when doing so. . . . [T]he Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail. In addition, covered entities will want to ensure that any transmission of electronic protected health information is in compliance with the HIPAA Security Rule requirements.
—US Department of Health and Human Services22
Many would advise that email with patients should only occur over a protected server that runs behind a firewall, and both sender and receiver must always be using encryption technology. But your institution or legal advisor may think differently and disagree that standard email is in compliance with the HIPAA Policy Rule as long as “reasonable safeguards” are in place.
Of course, using personal email is quite different from using secure patient portals such as MyChart offered increasingly by institutions and physicians. But many patients are more familiar with their own email accounts and often try to use them to communicate directly with their doctors instead of through secure patient portals. (For more information about portals, see section on Electronic Patient Portals and E-Visits.)
It seems that more patients of all ages want to email with their doctors for a variety of reasons. Foremost are the convenience and ease. Getting a quick answer from your doctor by email without having to make an office visit or leave phone messages is more appealing for most patients. Nils Bruzelius writes about his experience with emailing his doctors:
I am a 71-year-old man who moved from Boston to Washington 17 years ago and have had a variety of experiences communicating with my doctors by email or other electronic means. I have seen several specialists but currently am most often in contact with my primary care provider (PCP) internist and my cardiologist, who have different attitudes toward using email. Their differing ages may have something to do with that, or it may simply reflect different attitudes toward patient privacy and the related legal risks.
My internist is in his mid-60s and shares a practice with one other physician. I have been his patient for about 16 years. He is explicit about not using email but provides some electronic access through a patient portal operated by a medical group. He used to accept and reply to individual electronic messages through that portal, which is cumbersome to use, but he stopped after a couple of years. I don’t know why. Now he uses the portal only to provide access to examination and lab results and his comments on them. To his credit, he is very generous with his time during office visits, but if I wish to ask a question at other times, I have to call and leave a message. He does return calls on weekdays, but not on weekends. When I call, the most common response is to ask me to come in to the office, often on the same day.
My cardiologist is in his early 40s and freely accepts and answers emails even on weekends. He is part of a large cardiology practice anchored at a major medical center. I have been his patient since I was diagnosed with nonsymptomatic (except for a fainting spell that led to the initial diagnosis) atrial fibrillation five years ago. I see him roughly every six months, and he has administered stress ultrasounds and carotid ultrasounds over the past two years. Those tests indicate that my coronary arteries are in reasonably good shape.
I am generally open about my medical conditions (including a prostatectomy three years ago) and have no issues that I consider personally embarrassing. I have no need to apply for new health or life insurance, so I have little personal anxiety about medical privacy. I do recognize that it’s an important issue. I can’t think of a medical problem I would be unwilling to discuss by email except something that indicated I had committed a crime or a sexual indiscretion. Happily, that has not occurred.
I am comfortable researching medical questions on my own with the Merck Manual or other print or online resources. However, they are rarely fully satisfying when I’m concerned about a newly developing symptom.
As recently as this spring, I had a reason to want to contact my cardiologist quickly over a weekend. I was in San Francisco, far away from home, when I developed a sharp pain in my upper left chest, a little below the collar bone. I know enough about the symptoms of a heart attack to think that it was probably something else, but I was puzzled and frightened. I had never experienced this kind of severe, unexplained pain in that location. I did not want to visit an emergency department if possible, but I did feel the need for reassurance. I emailed my cardiologist at 10:41 p.m. on a Sunday evening, and he sent a reassuring response at 9 a.m. the next morning. I did not consider trying to contact my internist because, among other things, I knew he would be difficult to reach. As it turned out, the pain receded over the next two days and has not returned. The cardiologist did do a stress ultrasound after I returned home, but it did not find a problem.
I definitely like being able to communicate with my physicians by email because of the timeliness and convenience, and I am careful not to overuse/abuse the access that my cardiologist provides. When the time comes to find a new PCP, I will certainly inquire about email access.
Physicians need to understand their patients’ evolving needs regarding electronic communication and try to adapt and be responsive. However, you will want your patients to understand the ground rules for using electronic communication. Obviously, email is not appropriate for emergency symptoms or concerning new signs. Chest pain, signs of a stroke, difficulty breathing, or other alarming symptoms would certainly be issues you would not want your patient emailing you about. Patients need to understand that alarming, complex, or lengthy exchanges may require a phone call, an office visit or a visit to the emergency department. Patients should know that their emails may not be answered quickly but may take several days for the physician or physician’s staff to read and to answer. Email messages about nonemergency or noncritical information, as well as concise or simple follow-up questions or inquiries about prescriptions or appointments, may be acceptable to both parties.
You will want to explain to your patients the risks of communicating electronic PHI through any electronic system. You may also want to talk to your employer or your institutional legal advisor about your email system, encryption options, and medical-legal risks as a physician.
Appropriate Use of Patient Email
Potentially appropriate topics for email may include brief clarification about a medication, follow-up visit, lab or x-ray results, nonurgent clinical treatment matters, information about chronic disease management, or appointment reminders. Potentially inappropriate topics range from emergency situations or serious symptoms and any time-sensitive inquiries to sensitive or highly confidential or personal information (e.g., psychiatric symptoms, pregnancy, end-of-life care, life-threatening conditions, HIV status, disability, and legal matters).
• Email communication requires the same professional standards as all patient communications.
• Gain permission from the patient verbally (put in EMR) or in writing to use email after reviewing potential limitations, including breaches of confidentiality and delays in response.
• Review types of medical communication with the patient that may be appropriate for email and what is not appropriate (e.g., emergencies, private information or personal in nature, lengthy or complex messages).
• Don’t use email to discuss a new problem or to relay personal messages to a patient (email is to augment or clarify information from clinic visits).
• Remind patients that all emails exchanges may be at risk for compromising their PHI.
• Remind patients that emails may still require a follow-up phone call or in-person visit.
You can certainly develop a standard form for your patients to read and sign regarding email communication, with information about the appropriate use of email such as prescription refills or questions about appointments, billing, or other nonurgent matters and the limits of security about private health information. You may want to inform them that office staff members may be reading their email and responding if this is true. You may also want to tell patients directly when and how they can expect a response from you or your office when using email.
Electronic Patient Portals and E-Visits
Unlike emails, secure patient portals, such as MyChart, TVR Communications, Sonifi Health, and GetWell Network, are confidential, encrypted, and protected. These types of patient portals are offered by institutions and allow patients a variety of options, including the ability to communicate with their doctor and healthcare team. The sophistication and ease of use vary between systems, but many secure portals allow patients to do a variety of activities, from tracking their health information and test results to gaining access to health education, connecting with providers, and even obtaining advice or medical care for a minor ailment. The portals offer patients the ability not only to exchange secure electronic messages with their providers but also to request appointments and prescription refills, ask simple nonurgent medical questions, read their notes, review follow-up advice, and receive reminders about regular health screening and other activities.
Patients are not always familiar with patient portal systems and often just want to use their personal email or a phone call for the same purposes that are usually provided by institutional system portals. The important difference between personal emails and patient portals are that secure portals are usually encrypted, protected and connected to the patient’s medical record.
Patients want easy and quick access to you and their health information, but they don’t always know how to do it personally or electronically. Patients may express interest in Web-based tools such as patient portals or other electronic methods to fill prescriptions or track their own lab results, but few are currently doing so. Many patients do not know that their doctor allows for electronic communication or that their hospital or healthcare organization offers patient portals. Some patients have been discouraged by the systems or are intimidated to try to use the portals. Other patients are unwilling to use electronic communication with their doctors even if they are available.
It seems that while electronic communications between patients and physicians are not yet fully developed, accepted, or integrated, it may only be a matter of time before they are. How, when, and why you decide to electronically communicate with your patients will most likely be based on your patients’ needs and desires as well as your own knowledge, familiarity, comfort, and institutional support and access to the technology. For primary care doctors, one wonders how many of the 830 million annual office visits per year could be eliminated by electronic communications. The American College of Physicians estimates that 20% of office visits might be eliminated with use of secure electronic communications between patients and physicians.
Patient portal visits or so-called e-visits may increase access to care and reduce the time required for some office visits—or replace some office visits altogether. A recent retrospective study involving chart reviews for nonemergent acute care of adults looked at the nature of care through e-visits and found that 90% of the patients surveyed after an e-visit reported a positive experience and 92% reported that the e-visit had replaced their in-person visit with their doctor.23 It seems that e-visits may be the next way we take care of patients for nonemergent acute common conditions. But similar to all communications with patients, the more of a relationship the doctor has developed over time with each patient, the more the likelihood that an e-visit for a common ailment will be accepted by both parties and be successful. Of course, e-visits will never replace the intimate, personal, and thoroughness of person-to-person care.
American Medical Association Guidelines for Electronic Communications
The American Medical Association (AMA) has specific guidelines regarding electronic communications between physicians and patients.24. According to the AMA, electronic communication can be a useful tool in the practice of medicine but it can raise unique issues especially regarding privacy and confidentiality of sensitive information.24
Educating patients on the risks and limitations of electronic communication, obtaining their consent, and allowing patients to decline the use of electronic communications are all outlined in the guidelines.24
When physicians engage in electronic communication, they hold the same ethical responsibilities to patients as they do during other clinical encounters. Any method of communication—virtual, telephonic, or in person—should be appropriate to the patient’s clinical need and to the information being conveyed.
—American Medical Association Guidelines: Electronic Communication with Patients, Code of Medical Ethics Opinion 2.3.1
Mayo Clinic Social Media Network. https://socialmedia.mayoclinic.org.
Kevin Pho and Susan Gay, Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices (Phoenix, MD: Greenbranch Publishing, 2013).Find this resource:
Eric Topol, The Patient Will See You Now: The Future of Medicine is in Your Hands; (New York: Basic Books, 2016).Find this resource:
Sherry Turkle, Reclaiming Conversation: The Power of Talk in the Digital Age, Reprint edition (New York: Penguin Books, 2016).Find this resource:
Robert Wachter, The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age (New York: McGraw-Hill Education, 2017).Find this resource:
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