Anonymous posts: Liberating or unprofessional?
■ Doctors who tweet incognito like the freedom to vent their frustrations with medical practice. Critics argue anonymity opens the door to posting questionable content.
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Some stressed-out physicians are seeking the seeming safety of anonymity to blog and tweet about the travails of their lives in medicine. The results can be funny, provocative and revealing, but to some eyes these anonymous accounts veer from physician professionalism.
One person who tweets anonymously is @BurbDoc, who describes himself as a suburban physician in the United States. He has garnered widespread notoriety and nearly 3,000 Twitter followers among physicians, health professionals and others for his acrid, vulgar tweets. @BurbDoc, who did not respond to an interview request made through Twitter, frequently insults patients who ask what he considers stupid questions, make unsuitable requests or don't comply with his medical advice.
"Let's see. You smoke two packs a day and want to know why you're wheezing, right?" @BurbDoc wrote in early July about a patient. "Okay, just wanted to clarify that point."
On Independence Day, he wrote, "God help me if you call the answering service and bother me today."
In defense of his bitingly sarcastic posts -- many of which are profane and could not be quoted here -- he tweeted, "Remember, folks, it's not that I don't care, it's just that I dislike certain patients."
@BurbDoc's tweets have drawn criticism from physicians who believe his accounts are written by a practicing doctor. If his comments go too far, research indicates he is not alone. Three percent of physician tweets contain "unprofessional content," according to an analysis of 260 doctors on Twitter published in the Feb. 9 Journal of the American Medical Association.
Physicians who write anonymously online say it affords them the opportunity to vent their frustrations with patients, colleagues, administrators and health plans with less fear of crossing legal and ethical lines.
They would like to avoid the fate of doctors such as Alexandra Thran, MD, a Rhode Island emergency physician who in April was fined $500 and reprimanded by her state medical board for posting information about a patient to her Facebook page. Though she did not include the patient's name in her post, she included enough information that the patient could be identified, according to the medical board. Dr. Thran's clinical privileges at the hospital were terminated as a result of the posting.
"False sense of security"
Physicians have a responsibility to maintain the same level of professional comportment online as they would in any other public setting, whether or not they are posting anonymously, said Bryan Vartabedian, MD, a pediatric gastroenterologist at Texas Children's Hospital in Houston.
"Doctors do need to vent," said Dr. Vartabedian, who blogs and tweets under his own name. "I limit that venting of frustration to my immediate working staff and to my immediate colleagues. I don't feel it's appropriate for me to relate my frustrations with patients in a public place where everybody can see them."
He teamed with the Mayo Clinic Center for Social Media to produce a June 30 YouTube video advising new medical residents about how to appropriately use social media. The video, which features several other physicians, warned against posting anonymously.
"Anonymity creates a false sense of security that somehow we can disclose things and say things that we otherwise wouldn't say," Dr. Vartabedian said. "Normally, when our name's on things we have to think about the repercussions of those things. It's a lack of accountability with anonymity that creates the problems and gets people into trouble."
Dr. Vartabedian helped spark a broad Internet discussion of the topic when he blogged about a series of tweets posted in May by someone writing as @mommy_doctor.
"On call," wrote the self-described anesthesiologist. "Urology resident told me that there's a 36-hour priapism that will likely need to go to OR. ... I'm dreading having to go talk to him. Poor thing must be freaking mortified."
There was little danger that the patient's privacy was violated by @mommy_doctor, who deleted her Twitter account shortly after her tweets drew scrutiny from physicians and others who accepted them as genuine posts about a patient's abnormal erection. But Dr. Vartabedian wrote that the @mommy_doctor episode was a "case in point for putting your name and maskless face behind everything you say."
A general surgeon who blogs and tweets anonymously says that he does so precisely because he wants to feel unrestricted when posting.
"I'm still working and I don't want to be walking down the hall and have someone say, 'That was a pretty risqué thing you said on Twitter the other day,' " said the doctor, who tweets as @Skepticscalpel and asked not to be identified by name in this story.
He believes, for example, that obesity is not a disease but rather a condition brought on by patients who do not exercise self-discipline. He has posted on that theme repeatedly, and wonders how such bluntness would be perceived by his obese patients if he wrote under his own name.
The chance to vent anonymously is attractive, given that places like the physicians' lounge at the hospital are fading in importance, the physician behind @Skepticscalpel said.
"The doctors' lounge is essentially a cobweb-filled ghost town. Doctors are so pressed for time and so stressed that they don't hang around in the doctors' lounge," he said. "Except for being a place to hang your coat and pick up your mail, it's not alive anymore."
Writing as a release
When he started blogging as Doctor Anonymous in 2006, Mike Sevilla, MD, used the outlet to frequently express his frustrations with noncompliant patients and as a way to process his emotions.
"If there was a case that was really on my mind here at the office or in the hospital, then I would write about it, then post it and be done with it," said Dr. Sevilla, a family physician in Salem, Ohio.
In March, Dr. Sevilla decided to start blogging and tweeting under his own name. He said he changed course, in part, because he realized that his anonymity was not secure. Dr. Sevilla no longer writes about specific patients and exercises more self-censorship. There was some value in writing anonymously, he said.
"I miss being able to share some of those raw, core emotions," he said. "A lot of that stuff I'd write and not edit it. I would just send it out as one take, kind of release it and then move on."
Other physicians who have written anonymously say that writing unkind things about patients should be separated from the question of anonymity.
"That kind of ranting -- it's unprofessional to do that in public," said Lucy E. Hornstein, MD, a Phoenixville, Pa., family physician blogger who went public when she wrote a book under her own name. "The idea that anonymity allows you to do publicly that which is only appropriate in the private sphere is wrong. ... My contention is that the Internet is public. That's my simple formulation."
Dr. Hornstein said that even when she blogged anonymously she wrote about patients respectfully and changed details about them in a further effort to protect their privacy.
"I did use the opportunity to be somewhat more flamboyant, a little more profane, curmudgeonly, bombastic," she said. Dr. Hornstein has "no regrets" about any of the posts she wrote anonymously and has not deleted them.
Drop keyboard, find mentor
The American Medical Association's ethics policy on social media does not explicitly advise against posting online anonymously, but warns, "Physicians must recognize that actions online and content posted ... can undermine public trust in the medical profession."
Standards of professionalism apply at all times, said Luis T. Sanchez, MD, director of the physician health program of the Massachusetts Medical Society. He added that venting online is probably not a useful way to deal with the emotional strain of medical practice.
"We're opening ourselves to a new medium of communication, and it's not clear whether it has any advantage. Someone can do it repeatedly and may not be getting any relief, satisfaction or closure," he said.
There are more appropriate ways of dealing with stress, such as exercise, meditation or talking with a physician mentor "instead of just blasting this stuff out," Dr. Sanchez said.
Physicians should "develop some skills so they don't have to unceremoniously vent in a way that doesn't do anything," he said. "Try going for a swim or a run."