BLADE ILLUSTRATION/ TOM FISHER Enlarge
To really get a patient's attention, say doctors, you must start from where they are.
And where they are these days may be on their phone or computer, tweeting, texting, posting on Facebook.
But Twitter, blogs, and text messaging aren't in the comfort zone of most physicians -- even if some of their patients crave that less formal and more accessible relationship.
Wary of laws governing professional conduct and patient privacy, confused by the complicated rules for different social networks and unsure about the consequences of changing how they interact with patients, many have stayed away.
Others, though, have dipped a toe or two into the virtual swirl. And some are pushing for a full-on plunge, saying social-media venues are too powerful to ignore.
"I feel physicians are obligated to be online," says Dr. Wendy Sue Swanson, a pediatrician at the Everett Clinic who tweets and blogs as Seattle Mama Doc. "If celebrities are going to be online, then we educated, practicing physicians had better be there, too."
Credible health information is now often overwhelmed by sales pitches or compelling stories from movie stars who confuse anecdote with evidence, Dr. Swanson says.
At a recent conference for health professionals focusing on the "thin ethical line" between professional boundaries and personal interests, Dr. Swanson, movie-star pretty herself and well spoken to boot, took the microphone.
"We're losing ground -- we're losing our stake, science is losing voice," she told the crowd at Seattle Children's annual Pediatric Bioethics Conference.
Dr. Swanson's approach leaves some doctors nonplused. Many say they want to "partner" with patients and realize doctors can no longer simply pontificate to patients who duly obey.
But Twitter? Blogs? Facebook? What about patients' privacy, about squeezing time -- unpaid, at that -- from an already overbooked day, about inadvertent unprofessional slip-ups?
And what if your patients want to "friend" you?
"I think that's just a really icky idea," said Dr. John Lantos, another conference speaker and director of the Children's Mercy Bioethics Center at Children's Mercy Hospital in Kansas City.
"I don't respond to 'friend' requests from patients," Dr. Lantos said. "What if all your patients were asking you to sleep with them? Does this mean I have to? You just say no."
Still, these tools are too powerful to ignore, Dr. Swanson said.
"The technology is changing the way I practice," said Dr. Swanson, 38. "It's changing the way I learn and understand, it's changing what I know about health care and about pediatrics."
Now, in real time, she knows what patients are talking about, who is influencing them, and what she needs to do to steer them toward scientific information.
Using social media, she can let families know that a crib setup pictured in a news story is dangerous for a baby, for example, or weigh in on a breast-feeding controversy.
"We have this really great tool to improve our partnership," she told her colleagues at the conference. "This is an incredible space and an incredible opportunity."
For doctors who couldn't imagine "friending" a patient or that the personal-professional boundary could blur to the point it could cause angst on either side, Dr. Jennifer Kesselheim, co-chair of the ethics advisory committee at Dana-Farber Cancer Institute in Boston, offered a few examples.
In one case, a young doctor bonded with the parents of a child with leukemia. Just before the child was to leave the hospital, the mother asked to "friend" the doctor, who agreed, expecting to see the family again and not wanting to insult them.
A few days later, he saw postings from the mother, including pictures from a bar, drinking to celebrate her child's hospital discharge.
TMI might well change the doctor's relationship with the family, Dr. Kesselheim said.
Doctors and medical students, too, have pushed online boundaries.
For medical students who have grown up with Facebook and Twitter, social media might be difficult to do without when they begin their professional lives.
A majority of medical schools surveyed report unprofessional online conduct by students, Dr. Kesselheim noted, but most have no social-media policy.
A recent survey found that 90 percent of state medical boards reported at least one online professional-standards violation by a doctor. In Rhode Island, an emergency-room doctor was fired for a Facebook post about an unnamed patient.
In some ways, social media present situations not unlike those in a small town, where doctors and patients might meet at church or in the grocery store, and doctors have to decide where the boundaries are. Chat at the church social? Attend a patient's funeral? Go to the family's house for lunch?
Probably no medical groups have had more experience at virtual visits with patients than Group Health Cooperative and Kaiser Permanente, which began secure patient-provider emailing nearly a decade ago.
"Our doctors email patients at home, on vacation, at work; we've gotten very comfortable with it," says Dr. Ted Eytan, formerly of Group Health and now heading Kaiser's 17,000-physician group. "It's been a huge change. It encourages physicians and nurses to think about patients in their whole life, not just medical care."
Dr. Matt Handley, a family doctor and medical director for quality and informatics at Group Health, says it's not difficult to draw a line. "I've gone skiing or cycling with patients who are friends," he says, and does "friend" some patients on Facebook.
In both cases, it's only with people he's actually friends with. And like those who counsel "elevator rules," he never talks about work on his Facebook page, he says.
To be a good doctor takes conversation, Dr. Handley says, and at the heart of conversation is a relationship. "The more you understand and know about a patient, the more you can understand what matters for them."
Surveys show patients, though influenced by celebrities, overwhelmingly trust their doctors for medical information. And some want to know them as people too.
Years ago, Dr. Swanson said, she believed it was unprofessional to answer that frequent question patients ask: "Doctor, what would you do … ?"
Then she saw actress Jenny McCarthy on Oprah, espousing a vaccine-autism link, a theory that has since been widely discredited by mainstream medicine. She realized how powerful personal stories are for patients, and now responds.
"They say, 'Dr. Swanson, did your son get his MMR shot on time?'
"I say 'Yep.' And they say, 'OK, we'll do it.' "
Dr. Jen Dyer was practicing as an endocrinologist in Ohio. Infrequent office visits, she found, weren't enough to motivate her young diabetic patients to get a grip on their blood-sugar levels.
But texting? OMG! Another story entirely. With a young medical student, Dr. Dyer, now a full-time tech entrepreneur, developed an app to automate weekly texts to patients.
She picked up a "cheeky, fun" name given her by a patient -- the "Endogoddess" -- as her Twitter handle, and began tweeting out tips, from links to medical articles on current topics to advice for handling insulin during a hot afternoon baseball game.
"I felt like it was part of my ethical duty," Dr. Dyer says.
As with many new technologies, said Dr. Lantos, the Kansas City doctor, it's not yet clear how social-media tools could -- or should -- be used in patient care.
"As we're using it, we're starting to figure out what it's good for, what it's bad for … what the risks and benefits are," he said. "We're starting to learn some lessons, but we're only starting to imagine what the possibilities should be."