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Thursday, February 18, 2010

Doctor, Patient, Friend: Blurring the Boundaries

“I would be careful,” a fellow physician cautioned, as I told of my plans to attend a patient’s birthday party. In my 12 years of clinical practice I have lived in the community in which I practice, less than two miles from my office. I encounter patients daily in the supermarket, at soccer games, swim meets and school events. I have had conversations with patients at parties, on the street, and while half-dressed in the locker room. With my foray into social networking, beginning with participation in Facebook in 2008, I have “friended” my patients in cyberspace. As such, I have allowed patients to know details of my personal life and beliefs. They inquire about my family and are aware of my hobbies and interests. Perhaps against my better judgment, we have talked politics and health reform. But what are the appropriate boundaries?

Clearly the doctor-patient relationship is a highly privileged one, in which private and confidential information is exchanged. The communication that occurs within this context is subject to unique rules, ethical, and legal boundaries, as described by the Health Insurance Portability and Accountability Act (HIPAA). Patients share information with their doctors that they would not share with a friend, a neighbor, a fellow school committee member or another soccer parent. Should a doctor back away from a blurring of these boundaries?

Online social networking has introduced new aspects to this old question. Dr. Sachin Jain expresses it well in a New England Journal of Medicine Perspective piece: “The anxiety I felt about crossing boundaries is an old problem in clinical medicine, but it has taken a different shape as it has migrated to this new medium.” Whether or not physicians should engage in relationships with patients within the context of sites such as Facebook or Twitter is a matter of ongoing discussion.

One blogger, Dr. Bryan Vartabedian, suggested that physicians might take the following precautionary measures to avoid trouble:

1. Have an offline discussion with patients who contact you via social networking regarding the confidentiality and privacy issues inherent in communicating in this manner.
2. Discuss with patients the need to document doctor-patient communication in the medical record.
3. Develop a personal social media policy to govern your interactions with patients via the internet and social networking sites.

These measures seem prudent to me.

Others have advocated that physician-users of Facebook have two pages, one personal and one professional. Those same physicians might hesitate to have coffee or dinner with a patient. Clearly Facebook and Twitter are never appropriate sites for discussing the details of an individual’s health or other information that could possibly be privileged and identifiable. Patients need to be aware that tweets show up on Google searches. Does this mean I shouldn’t enjoy seeing pictures of a patient and her family, or getting to know her better through her status updates, sense of humor, likes and dislikes? In contrast, I believe that through this type of sharing the doctor-patient bond can be strengthened and trust enhanced. My view is that allowing some blending of doctor-patient-friend roles is likely to enhance the individualized advice that I am able to give my patients about their health problems.

With proposed changes to our primary care delivery model, “The Patient-Centered Medical Home,” we are looking at using electronic systems to care for populations of patients in part to compensate for inadequate numbers of primary care physicians. The proposed model would enlist care teams, including a single physician, to provide care for up to 5,000 patients (most primary care physicians currently care for two to three thousand). A system of automatic reminders, feedback on quality indicators, and decision support tools would ensure high quality care in this idealized model. But what happens to the doctor-patient relationship? So I say, lets not be so stymied by legalism that we are afraid to befriend our patients.


  1. I have accounts on two social networking sites: Facebook and LinkedIn. I am careful to separate work from play when expanding my friend network on both sites, keeping business colleagues isolated to LinkedIn, and casual friends limited to Facebook. With these personal guidelines in place, I can feel confident that any content I share on either site is only seen by the appropriate audience. In essence, I'm using these sites for their intended purpose.

    When it comes to doctor-patient interaction on social networking sites, the same separation of work and play should apply. Can a doctor be friends with a patient? Of course. Can a patient be a colleague of a doctor? Again, yes. Therefore, sites like FB and LI can play a role in maintaining those relationships. However, a line needs to be drawn between social communication and professional medical communication. This line need not be defined by the law, but rather as a personal guideline for both patients and doctors. Consider it something like social networking etiquette.

    I have many friends who are doctors, and I particularly enjoy engaging them in intellectually stimulating conversations, even controversial issues such as creation vs. evolution, abortion, health care reform, etc. I see no reason why these types of discussions should become off-limits if I were ever to become a patient of one of these doctor friends, nor would I feel obligated to refrain from attending a doctor's birthday party or ski trip. In the end, it's not the medium in which patients and doctors communicate that's of concern, it's the topic of the conversation.

  2. speaking as a (chronically ill) patient- who wants to become a doctor- i think that very often, "the care and the cure are one in the same" (p.s. that's my own, trademarked phrase- so cite me, please). sure, i go to the doctor and develop a clinical relationship for the purpose of increased physical wellness- in an *attempt* to assuage my symptoms and eliminate or quiet-down the disease process(es) behind them. nevertheless, i know from experience that medicine is part science and part art, an inexact endeavor. for this reason, the patient-doctor relationship can sometimes feel like "the blind leading the blind," and as a patient, i respect the doctor who acknowledges that we are stumbling together.

    contrary to popular opinion, most chronically ill patients are in agreement: we don't expect to be cured by our MDs. in fact, most don't expect radical changes in our disease profiles. i think of wellness- significant clinical improvement- as an added bonus. call me cynical, but i know i'm not alone.

    so, why do i go to the doctor? i go to be heard. i go to have my symptoms-and my feelings, thoughts, and research about my symptoms- validated, considered. i go to prevent further onslaught of disease; maintain some semblance of wellness; report changes; and finally, to visit my "medical home," to pay my doctor- my medical parent, of sorts- a visit. as a patient, i would like my "medical home" to be just that- a 'home,' drawing on the denotative aspects of the term. in theory- and if one is lucky, in reality too- a home is a safe space, where one can speak freely, garner support, ask for advice, and return to, repeatedly.

    the doctor-patient-friend relationship is essential to the creation of this sense of 'home' for patient and provider; it is built on bidirectional communication and transparency. like i said, the care and the cure are one in the same- sure, you can get rid of your sinus infection if your MD tosses you a Z-pak and walks out of the exam room without acknowledging you, but you're not going to feel very *well* about that. if an annual sinus infection is the extent of your health issues, then perhaps this lack of interaction doesn't matter as much. however, to the chronically ill patient- and to most patients, i believe- the relationship is tantamount if not paramount. the doctors i remember, those that i am thankful for at the end of the day, aren't those that "treat 'em and street 'em," but those who take the time to see, hear, and speak to me- who consider me before my diseases, and make room for me in their lives and medical homes. in my opinion, it is in the blurring of the boundaries between the professional and the familiar that medicine- and healing- really take place.

  3. Thanks for these great comments. Morgan Amanda points out that the changes in communication that occur because of blurring of boundaries may lead to better understanding between doctors and patients and enhanced trust. Novox77, I agree with the importance of distinguishing social communication from professional medical communication. I would argue, however, that that does not necessarily imply that patients and doctors should not engage in social communication on sites such as Facebook, provided that the "rules" and privacy concerns are understood. In terms of separating my professional and personal persona online, my take on this is that I would be reluctant to post anything on Facebook that I deem as incompatible with my professional persona.

  4. Great post! I just wanted to add that in order to develop a thorough personal social media policy, it becomes necessary for the physician to fully explore all the services out there, with all their features, limitations, and side-effects. Like you mentioned, patients may not realize that tweets show up on Google search - and with almost shocking expedience (I guess because the algorithm rewards frequently-updated pages). Another example: I for one was kind of put off when the recent introduction of Google Buzz made all my contacts and posts show up automatically on the internet for the world to see. So, while social media can enrich doctor-patient relationships, it is becoming crucial to obtain pre-emptive online literacy, and then use that knowledge to avoid privacy debacles with patients. I think there is certainly some responsibility on the health provider's part to inform them of these issues.