The digital revolution has had a profound impact on medicine and patient care. Patients have a growing expectation that they can find medical information on the web and discuss it with their physician by e-mail (1). Physicians, including psychiatrists, are increasingly using blogs and Twitter to promote their practices (2, 3). The internet itself is used as a vehicle for therapeutic modalities, even psychotherapy (4). Social networking among patients, physicians, and other “friends” are blurring boundaries as never before (5, 6).
The potential clinical, legal, ethical, and professionalism issues in using the internet and digital media in psychiatry have been outlined elsewhere, including explicit recommendations for resident education in this area (7). This article focuses on how to teach residents about appropriate use of the internet.
The evidence of unprofessional online behavior among physicians and the complexity of the potential issues raised with internet use in psychiatry suggest that psychiatric residents, educators, and administrators need explicit teaching about potential clinical, ethical, and legal pitfalls of internet use. In 2010, the President of the American Association of Directors of Psychiatric Residency Training (AADPRT) established a Taskforce on Professionalism and the Internet, charged with reviewing the literature and creating a curriculum to teach psychiatric trainees about online professionalism. Participants in a Taskforce-run workshop on this subject were asked for examples from their own experience of online professionalism concerns (8), and an outpouring of vignettes ensued. The Taskforce undertook to create a curriculum based on vignettes designed to promote similar discussion. The principles elicited in these vignettes might be seen as extensions of well-established principles of professionalism (9, 10). Trainees accustomed to continual use of interactive technologies, however, may overlook boundary and other professionalism issues if they are not made explicit in training. The curriculum strives to address principles, rather than specific technologies, since the latter are expected to continue to evolve rapidly.
The vignettes in this curriculum (available online at aadprt.org (11)) are designed for either group discussion or individual study; they are accompanied by relevant references and a teacher’s guide. The vignettes are organized around nine issues that may be relevant to various teaching venues: liability, confidentiality, and privacy; psychotherapy and boundaries; safety issues; mandated reporting; libel; conflicts of interest; academic honesty; “netiquette;” and professionalism remediation. We discuss the first eight of these topics, using vignettes from the curriculum for illustration. Where vignettes are based on actual cases, all identifying details are disguised.
Internet technology has the potential to improve patient care, but poses new challenges in medical liability. E-mail, in particular, is increasingly common between patients and physicians, sometimes improved by protected portals and encryption systems that safeguard confidentiality (1, 12, 13). Residents require training about clinical challenges posed by online technology. For example, e-mail is limited by the loss of nonverbal cues, and meanings may be misconstrued. Communication and diagnostic errors may be made, emergency situations missed, and physicians may “head down a slippery slope” of e-mail exchanges without setting appropriate limits about when the patient needs to be seen (11) (Vignette #12). A key issue is response time: Given 24/7 e-mail access, are physicians responsible for rapidly responding to e-mails (14)? Consider this clinical vignette:
A psychiatrist returns from a long weekend away and checks his e-mail to find an urgent message from a patient reporting that her depression is significantly worse and she is feeling actively suicidal. The psychiatrist is very upset because he had carefully signed out his beeper to a colleague and left a message on his office voicemail saying he would be away, and patients in an urgent situation should contact the covering psychiatrist. The psychiatrist had communicated by e-mail with the patient on a number of different occasions, but had always told the patient that e-mail was not the best way to reach him in urgent situations. The psychiatrist is even more upset when he learns that the patient did, indeed, make a suicide attempt and has been hospitalized (11). (Vignette #11)
Such vignettes can be used to teach the importance of having patients sign a consent form for e-mail communication that establishes turnaround time for messages, restriction on non-urgent use, appropriate message headers, privacy and confidentiality issues, and permissible content.
Also, residents need to learn about institutional and legal standards as they develop, and the fact that electronic communication is subject to discovery. Once psychiatrists have established a doctor–patient relationship by providing online advice to a consenting patient, liability issues may arise—psychiatrists may be liable if e-mails are not saved into the record or if response time is not adequate (14).
E-mail is just the beginning: psychiatrists are communicating by text and “tweet,” and new technologies for interfacing with patients are undoubtedly on the way. Technology should be used in a boundaried, confidential fashion, with the patient’s written consent, to support,rather than to establish or maintain, the doctor–patient relationship.
Violation of patient privacy and confidentiality through social-networking sites such as Facebook and Twitter is a significant problem in healthcare settings (7). Numerous media reports have documented hospital and clinic staff members posting photographs and identifiable information about patients; in some of these situations, staff are terminated as a consequence (15, 16).
Many hospitals have developed, or are in process of developing, policies for the use of social-networking sites in the workplace (17). Medical students, residents, staff, and attending physicians must be educated about the appropriate use of such sites. In doing so, medical educators need to acknowledge that younger physicians use technology as an integral part of their personal life, as recognized by the American Medical Association (AMA) in its policy on Professionalism in the Use of Social Media (18).
Given long work-hours, clinical inexperience, and, sometimes, lack of personal support, residents may be quick to express online their thoughts and feelings about work stresses. They must be trained to be mindful that any divulged information that could lead to the identification of a patient would be a violation of the Health Insurance Portability and Accountability Act (HIPAA) (19). Consider the following example:
“Dr. A,” a psychiatry resident leaving his on-call shift in the emergency room at a local hospital, decides to send his friends a Facebook update. “Just finished with a lousy, 24-year-old jerk,” Dr. A writes. “A soldier complaining of pain = addict.” “Dr. B,” who is an emergency medicine resident in the same local hospital, and Dr. A’s Facebook friend, sees the status update on his smart phone just before going in to see a 24-year-old male patient with a military history who is complaining of pain (11). (Vignette #31)
In a teaching session, residents can note the obvious HIPAA violation, but also consider the professionalism breech, and how such a breech may have a negative impact on the whole profession (20, 21). Residents must learn to manage their feelings about patients in more appropriate settings, such as supervision and their own individual psychotherapy.
The AMA suggests separating professional online information from personal online content (18). Privacy settings can help to safeguard personal and sensitive information from the general viewing public. Residents should be guided to helpful resources like ZDNET’s The Definitive Facebook Lockdown Guide (22) about how to apply good privacy settings. Also, residents should learn to regularly check search engines like Google, Yahoo, and Bing to be aware of their “web-face” and take appropriate action when necessary to “wash” it (7, 23). However, as the AMA policy warns, residents must be careful about a false sense of security, as “privacy settings are not absolute and that once on the Internet, content is likely there permanently.”
Given the rapidity, breadth, intimacy, and potential permanence of internet communication, psychotherapy learners need help in navigating this major shift from traditional communication styles (7, 24). The psychotherapy principles of neutrality, anonymity, and abstinence may be compromised when a patient accesses trainees’ postings, which may date from before their professional education. Unfortunately, such postings may include information that compromises professional identity and undermines the patient’s comfort in candidly communicating sensitive material, which is so fundamental to successful psychotherapy (7).
Residents need to anticipate being confronted by patients regarding online content about their psychiatrist. Dealing with inaccuracies or indiscretions without adding unhelpful amounts of self-disclosure (in the service of neutrality and anonymity) is a difficult clinical problem. Some important potential situations to consider in a teaching session include: the impact of a patient’s discovering the psychiatrist’s sexual orientation online; how a psychiatrist with unconscious unmet emotional needs can lose sight of appropriate boundaries by engaging in intimate e-mail exchanges with patients; how a particularly troubled patient can assume a false identity online to “friend” and ultimately stalk the psychiatrist. Vignettes on such topics can be used to stage role-plays (with residents playing the therapist and patient) that promote open-ended discussion about confronting and managing these kinds of clinical dilemmas.
The use of e-mail communication with patients is extremely complex (25) and requires special attention in teaching residents. E-mail communication with patients has been used successfully, including as a way to test the safety of the treatment relationship (26). But the clinical, ethical, and liability concerns described above must be considered. In child and adolescent psychotherapy practice, e-mail and other technological communication may add a new dimension to issues around separation and individuation, or appropriate parent–child boundaries. For many patients, written policies or principles regarding electronic communication will need to be revisited in times of crisis.
When patients or their potential victims appear to be in danger, we are required to report these unsafe situations to appropriate authorities. Until recently, such investigations were based on patient-observation, reporting, and clinical assessment, as well as direct contact with collateral informants. The availability of personal information online has opened up entirely new sources of information about patient behavior to clinicians. Increasingly, psychiatrists are carrying out information-searches about patients (so-called “patient-targeted googling”) (27). Few articles have been published regarding the extent, circumstances, and reasons used by clinicians to justify online patient searches (7). The APA Ethics Committee (2009) offered the following guidelines (27):
Googling a patient is not necessarily unethical. However, it should be done only in the interests of promoting the patient’s care and well-being and never to satisfy the curiosity or other needs of the psychiatrist. Also important to consider is how such information will influence treatment and how the clinician will ultimately use this information.
A pragmatic framework offered by Clinton et al. (28) suggests that clinicians consider six questions before searching online for patient information:
Why do I want to conduct this search?
Would my search advance or compromise the treatment?
Should I obtain informed consent from the patient prior to searching?
Should I share the results of the search with the patient?
Should I document the findings of the search in the medical record?
How do I monitor my motivations and the ongoing risk–benefit profile of searching?
The authors provide case-vignettes that can be easily adapted for teaching purposes. One of them is particularly compelling because it raises safety and mandatory-reporting issues. The gist of the case follows:
A 16-year-old girl is seen by a resident in the Psychiatric Emergency Department for very troubling behaviors (missing school, staying out past curfew, receiving failing grades), which started after she entered into a relationship with a 35-year-old man. During the interview, the resident learns that the patient’s boyfriend has been taking provocative pictures of her and posting them on his website. The patient’s mother is unaware of the photographs. The resident decides to search for these pictures online (28).
A useful teaching approach is to hold a debate on the resident’s decision, with one side coming up with reasons justifying the online search and the other advancing arguments against this decision. Here, the thought process, not a single right answer, is the key.
Defamation is the communication of false information, stated as fact, which brings harm to the individual about whom the information is communicated. Written defamatory content, including online content, constitutes libel (29). Thus, patient-generated material on social-networking sites, blogs, or physician-rating websites (30) may be considered libelous if it is both untrue and harmful to the physician. Residents need to be aware of web-based content about them (31); however, residents also need to learn how to approach the discovery of negative content. Consider the following example:
An early-career psychiatrist discovers that, on an online physician rating site, someone has submitted a negative review of the psychiatrist, [alleging that] the psychiatrist “occasionally violated my civil rights.” The psychiatrist is concerned about the potential impact to his reputation as he begins practice if this review is available on the website…The psychiatrist considers whether to submit positive reviews under various pseudonyms, pretending that they are written by real patients, to create a more favorable impression of the psychiatrist on the website (11). (Vignette #15)
In this case, the single report is unlikely to harm the young psychiatrist, and posting pseudonymous reviews will not improve the psychiatrist’s ethical position. Rather than acting out his feelings, the psychiatrist may benefit from a supervisory consultation. Unfortunately, some disgruntled individuals can post false and harmful content online; residents need to recognize such defamation, and seek legal counsel and/or the services of a reputation defender company.
Because psychiatrists often hold various roles at once, including those of educators, patient advocates, scholars, researchers, and consultants to industry, they need to be aware of potential conflicts of interest. Roberts and Hoop (32) define conflict of interest in medicine as “a situation in which a physician has competing roles, relationships, or interests that could potentially interfere with the ability to care for patients.” In learning about conflict of interest in medicine, psychiatric residents now must learn about how it can apply to online behavior.
A physician may take an online role or express opinions that are not aligned with his or her professional responsibilities to patients or colleagues. Here are some examples:
Responding to an online survey or social-networking site, a physician endorses a particular pharmaceutical company for which she serves as a speaker.
A resident makes derogatory comments about his current hospital service in an online blog.
A medical student posts his political opinions regarding an advocacy organization on his Facebook page.
The possibility of online anonymity presents other temptations, as described in the following vignette:
A junior faculty member has co-written her first chapter in a text about psychotherapy that is edited by a well-known psychiatrist…Some months after publication, the junior faculty member is asked to respond anonymously to a national online survey of faculty members about recommended textbooks for teaching psychotherapy to residents…The faculty member…write[s] a positive review and resounding endorsement of the textbook to which she had contributed…(11) (Vignette #24).
Psychiatric educators can use this vignette to help residents delineate the clear conflict of interest between the faculty member’s role as a chapter author and her role in providing an anonymous online endorsement of the book to her professional colleagues. Ethics guidelines by professional organizations can be referenced (33, 34).
The availability of numerous professional e-mail lists, websites, and anonymous surveys presents new opportunities for missteps and poor judgment with regard to conflicts of interest. Recognizing and disclosing potential conflicts so that others are aware of possible bias is the take-home point.
Like the clinical setting, the academic setting is both enhanced and challenged by the digital age. Accessibility makes the comprehensive research of a subject more efficient than the print medium. Unfortunately, plagiarism is more efficient as well. “Paraphrase plagiarism,” in which a writer copies and then changes a few words from another author’s work and presents it as original, is a common hazard. One survey of undergraduate students found that 19% “occasionally” and 10% “frequently” copied text without attribution (35); another survey of students at 23 different colleges found that 38% admitted to at least one instance of paraphrase plagiarism in the past year (36). These decade-old surveys likely underestimate the problem. Online services such as “The Doctor Job” (37) can “help” residency applicants. Some program directors have resorted to plagiarism-checkers, such as “Turnitin” (38).
The internet did not create plagiarism, nor has it necessarily increased the rates (39). One might then assume that the current policies on academic honesty at academic institutions are sufficient. However, trainees who have grown up in an age of file-sharing, web linking, wikis, and music sampling may find concepts of ownership, originality, and copyright more difficult to grasp. Consider the following example:
On reading a student’s paper, a professor notes a strong resemblance to a Wikipedia article on the subject, including verbatim quotes used without attribution. When confronted, the student is perplexed and explains that, as the material is public domain and has no specific author, it is not plagiarism. Furthermore, she argues that, although she ‘cut and pasted’ text from the Wiki, the organization and conclusions were her own, and thus she was not intellectually dishonest (11). (Vignette #26)
Although older generations will likely interpret this vignette as clear-cut plagiarism, younger psychiatrists may be less convinced, and this attitudinal difference may demonstrate a fundamental cultural change (40). For example, when the content of a recently published online novel was found to include unattributed extended passages from blogs and other online sources, the young author’s defense was that she represents a new generation of artists who freely “mix and match media to create something new” (41). The novel remains a best-seller and was a literary award finalist. As the anthropologist Susan D. Blum suggests, the concept of plagiarism “is changing because, in higher education, the meaning of a ‘text,’ and notions of the self are changing around it” (42). If this is true, then insisting on adherence to existing rules of academic honesty may not be sufficient. Educators must reconsider the philosophy behind academic honesty and find ways to teach it in a manner that is relevant to trainees’ own experience and values.
Although medical students learn how to interact professionally with patients and staff, such lessons on interpersonal and professional etiquette may not cover the potential pitfalls of electronic communication. Most electronic communication relies on the written word and visual image, and does not provide nonverbal cues about the sender. Thus, details such as the greeting, specific word choice, and punctuation (including emphasis techniques such as bold-facing), may have heightened impact and determine how the message is heard, (which may be different from the sender’s intent). The rapidity of electronic exchange invites rapid-fire responses—pausing before responding to an e-mail or a text can be an important lesson to learn. Finally, technology provides ways for messages to be quickly disseminated beyond the initial intended recipient, not always with that person’s knowledge. Learning when to set a limit on forwarding texts, e-mails, and other online information is an important skill (43, 44). Here is an example:
A program director (PD) receives an e-mail from a supervisor delineating concerns about a resident’s performance. The supervisor makes reference to the resident’s “arrogant manner” and “narcissistic need to dominate conversations.”… The PD… forwards the supervisor’s e-mail to all seminar leaders and rotation supervisors and asks for their response (11). (Vignette #19)
This vignette can be used to discuss the inappropriate use of e-mail that includes confidential material, emotionally-charged language, and personal attack. The PD’s decision to forward the initial e-mail only magnifies the problem. In a teaching session, residents can brainstorm as to how the PD might have better managed this situation. A key teaching-point: Technology should never serve to discharge feelings that are better worked through in supervision or therapy.
The current generation of learners relates to the internet more as an extension of themselves than as an external resource. Interactive technologies have fostered new attitudes toward privacy and boundaries that must be explicitly addressed in the process of becoming a physician, particularly in psychiatry. Physicians must carefully construct their online personae in a manner consistent with long-standing principles of professionalism. Just as discussions on interaction with industry have helped prepare trainees for practice realities, thoughtful discussion of online professionalism and boundary issues during training will lead to better decisions by graduates as they establish their practices. (See Table 1.)
TABLE 1.Recommendations for Teaching About Professionalism and the Internet
| Add to My POL
|1. Acknowledge and respect different attitudes toward digital media across generations.|
|2. Don’t assume trainees recognize professionalism issues; make them explicit.|
|3. Teach interactively using vignettes familiar to the residents’ own experience.|
|4. Include vignettes that cover the eight topics outlined above: Liability, Confidentiality and Privacy, Psychotherapy and Boundaries, Safety Issues, Libel, Conflicts of Interest, Academic Issues, and “Netiquette.”|
|5. Provide references, including institutional guidelines and policies, professional codes of ethics, and recommendations for maintaining a professional online identity.|
|6. Emphasize overarching principles and concepts, rather than technological details that are likely to change over time.|
The curriculum suggested in this article represents an easy-to-implement educational intervention to foster these discussions. Public perceptions of psychiatry and the field of medicine risk being discolored by the online behavior of members of our profession. It is up to psychiatric educators to train a new generation of psychiatrists to think through the professionalism issues raised by online technology, including technologies not yet invented.
Members of the AADPRT Task Force on Professionalism and the Internet are Sandra M. DeJong, M.D. (chair), Joan Anzia, M.D., Sheldon Benjamin, M.D., Robert Boland, M.D., Nadyah John, M.D., James Lomax, M.D., and Anthony Rostain, M.D.
At the time of submission, the authors reported no competing interests.