GMC Guidance on social media use by doctors. St.Emlyn’s

Firstly apologies for the slow updates of late. I am ‘away from the desk’ so to speak, having a lovely time and all, but there are certain restrictions on internet access!

Anyway……..the GMC guidance has arrived.

Most if not all doctors should have received an email from the GMC today regarding an update to General Medical Practice which is the code of conduct for all doctors registered in the UK. If you haven’t read it already you really should as it serves two major purposes in my opinion.

  • 1. It tells you what you should be doing as a clinician.
  • 2. It tells you what you should not do if you want to stay working as a clinician.

That may sound ominous but as doctors we hold priviliged positions in society and it is important that we behave in the best interests of our patients. So have a read, but in particular have a look at the explanatory notes regarding doctors use of social media as I believe that this is an area that worries many social media active docs, even those that I really repect like Jeremy Harrison.

One of the big changes will be that doctors are instructed not to use pseudonyms on social media types like twitter. This will mean a big change for many docs who prefer to separate the two. I took the advice of Mike Cadogan last year (@sandnsurf) that it is best to tweet with my real name as it can be traced back anyway and it you’re less likely to say something stupid if it has your real name attached. That works for me, but not for all people in this space and I suspect we will see some great contributors leaving (though hopefully they might return with real name intact).

Thankfully and wisely the majority of the advice in regard to social media use is largely a reflection of the GMC’s advice in all other areas, though it recognises that the environment of social media means that new circumstances exist in which traditional principles apply, but where they might need clarification.

So, this is mostly a reiteration of old guidance re-organised to reflect social media environments and that’s fine. What is particularly important to me, and I think to many others are those areas where the relationships with patients might be compromised. Foremost here is the re-iteration of the rules around confidentiality.  They are worth repeating……

Maintaining confidentiality
12 Many doctors use professional social media sites that are not accessible to the public. Such sites can be useful places to find advice about current practice in specific circumstances. However, you must still be careful not to share identifiable information about patients.

13 Although individual pieces of information may not breach confidentiality on their own, the sum of published information online could be enough to identify a patient or someone close to them.

14 You must not use publicly accessible social media to discuss individual patients or their care with those patients or anyone else.

If you spend a lot of time communicating with colleagues in other health systems around the world you will soon realise that the rules with regard to confidentiality do differ depending on your area of practice and your local regulator and I see this is a potential area where UK doctors could get caught out. A look over my twitter timeline on any day of the week would find examples of international colleagues potentially breaking elements of the above and I can imagine that it would be all too easy to join in with a local patient story that strays across into a breach of confidentiality. In particular point 13 alludes to unintentional linking of information such as times and places that are often revealed through twitter. A common example might be ‘a patient has just walked in with X wrong with them’, in general it is pretty easy to work out who posted this, where they work, and what kind of work they do. All too easily it can then be linked to a patient and trouble ensues.

So what are we to do? Doctors and indeed all clinicians have used patient stories to teach and learn since the time of Hippocrates and we still do, though usually in closed spaces that are bounded by time and place (the traditional grand round for example). However, with the potential sharing of real cases in the social media space and even via the broadcast (webcast) of traditional meetings we do risk allowing what was once enclosed information to seep out through the porosity of social media, sometimes far beyond where it was first intended and with the potential to deliver harm to patients, relatives and colleagues.

What then?

Sir_William_OslerIt was William Osler (who knows a thing or two about teaching) who said

“To study the phenomenon of disease without books is to sail an uncharted sea,

while to study books without patients is not to go to sea at all.”

Well, like clinicians of old we feel that if cases must be used to deliver key teaching points (and they often are) then the way forward is for them to be created, imagined, developed and perhaps inspired by reality but that they should remain distant from the truth and not reflect people or circumstances that link them to individuals. Whilst this may arguably detract from the fidelity of any story it seems that this is the sensible and safe way forward for ourselves and colleagues who seek to improve patient care through social media. This is essentially the same process as writing for text books for publication. It is presumably fine to talk about typical presentations and circumstances but not in a way that risks revealing a person, time or place.

However, I am still a little concerned about the potential for misinterpretation and coincidence though. We had a case on St.Emlyn’s (non clinical) where a colleague thought that it was talking about them. It was not and but was in fact based upon a made up scenario, but like all the best made up scenarios it was believable – so believable in fact that it mirrored the identity of a different physician. This was entirely accidental and resolved quickly through professional conversation. However, such a co-incidence might be more tricky to manage with patients. For example if I started a case with…..

“A woman in her 20’s is brought to the ED following a fall whilst intoxicated. She has

fallen onto her outstretched hand and is complaining of pain in the wrist……’

Clearly there have been many such cases, you can also work out where I work, and I might associate an anonymised X-ray of a scaphoid fracture as an illustration to invigorate a blog post on imaging for occult wrist fractures. Could this land a blogger in trouble? There are two questions for me which are not covered in the guidance.

  • 1. To break confidentiality does the ‘patient/doc/colleague/relative’ have to notice or can such a breach be reported by others (important as there are people out there who might enjoy reporting bloggers).
  • 2. Is co-incidence a defence, because if it isn’t then I suspect William Osler might be spinning in his grave.

So, these are interesting times, with a range of media that might catch out the unwary. I also wonder if this is the start of a much wider debate, in days past the authorities found it difficult to silence the printing press, but in the meantime my advice is to think carefully before posting.

vb

S

16 Comments

  1. David Drake

    How about a reverse situation: a clinical scenario discussed in a closed forum between clinicians for educational purposes in an anonymised fashion…and then the patient’s identity becomes public knowledge later through other publicly accessed media as a newsworthy item due to its inherent unusual or public health implications. But because the publicly accessed news item is in itself educational to the original clinicians involved in the closed forum discussion, would it then be kosher to bring that information back into the discussion but risk breaking confidentiality? Is it breaking confidentiality when the patient’s identity is already public knowledge accessible through non-social public media? Or despite knowledge of a patient’s identity publicly is it still appropriate to discuss certain elements of the clinical management in a closed medium? Open medium? Why the difference if any?

    Sensible (ha!) as I think I am, I still feel somewhat uneasy about the whole thing, something visceral I can’t quite articulate…

    Reply
  2. John Cronin (@croninjj)

    Excellent commentary. I heard of some “unwritten rule” that one should wait 2 years before blogging about a case. That did not make much sense to me as 1) it was unwritten, 2) it means you have to wait a considerable time to share your learning point, and 3) someone, as in your case, could mistake it for themselves anyway.

    One useful approach could be to open a case discussion with: “This is a case I saw in a another hospital I worked in some time back….”. Not fool-proof, but adds another layer of distancing it from a real case.

    Reply
  3. caseyparker207

    HI Simon
    Great points and update on this vexatious issue.

    Just for fun I thought I would throw a few scenarios at you – to illustrate some ad absurdum points.

    (1) A group of junior Docs are having a pint at the pub up the road from St Emlyns after a long shift. One says: “That guy with the scaphoid fracture was a total tool bag!”
    At the next table over is a woman who turns out to be the mother of a young man treated at the hospital that day for a scaphoid fracture.

    Now – clearly it is unprofessional to talk about patient’s in this manner in a public venue – I suspect it is extremely common though.
    In terms of identifiability – the geography of the situation makes it likely that they have breeched the NAPA rules. However, this could be a coincidence – a handful of scaphoids may have been treated that day – they are not all “tool bags”

    (2) A psychiatrist take a year off to write a novel. He/she writes about a troubled young lady who suffered sexual abuse and developed borderline tendencies before overcoming her demons to become an international yoga star.

    She publishes this under her own name, and it sells like hot cakes – a million copies worldwide. It win “Best Fiction” at some book prize or another

    A former patient now living in another country recognizes components of the story in her own history. She complains: breech of confidence! Is the defense: “coincidence” going to work here? Even if the author was completely unconscious of any link with this patient?

    In my world I am writing fiction, but all fiction is based in experience. The majority of patients I encounter are happy to have their story old for the sake of education and prophylaxis for future repetition of errors they have suffered.
    AS you say – there will always be a few folk with an axe to grind who will make it tricky – but should we completely avoid case-based online learning for this minority?

    Thoughts?
    Casey

    Reply
  4. Haidar

    Really good to hear this discussion being had.

    Not too long ago I had a similar discussion about a middle aged man’s entirely normal wrist X-ray I wanted to share online.

    Did I need consent for this, bearing in mind the descriptive sentence I have shared with you above is a greater breach of confidence than the image would ever be to most people as it tells everyone the sex and rough age of the patient.

    I guess what I am saying is that words can be far more revealing than images, and far more judgemental, insulting, and powerful. But they always have been to those who have the power to get their words and opinions out there.

    It’s just that modernity allows anyone to get their words & pictures out there. This is a greater issue for us than it will be for the next generations. We are the one’s faced with figuring out this novelty and how we fit into it. For them it is their absolute normality, the reality which they grew up with, and their relation with their social presence will be deeply engrained in their behaviours long before they become doctors.

    Many of us have two accounts. I hear much about the strengths and weaknesses of different platforms, of the difference between publishing and broadcasting, the difference between open and closed networks. Every time I do I wonder if this is just my generation failing to grasp that things have changed, and that the explosion in the number of platforms of varying shades of openness will continue as will their use.

    Future generations will have a single identity and relationships within a number of platforms of varying openness that they won’t want to change when they start as doctors one hot August afternoon, instantly losing huge swathes of their historical connections and timelines. They won’t apply a test to see where they put what, they will simply know. Also they will invariably assume most social media is entirely open and eternal.

    They will know that their social media tells companies about their likely politik & social norms (http://alturl.com/zjecz), informs insurers about their behaviours, targets their buying habits, essentially pervades their life.

    What they know about their behaviour in relation to medicine should come from us at medical school, from an understanding of ethics and the principles of confidentiality. I don’t see that any specific new edict from the GMC is required. This feels like a triumph of committee over reason, a reflex need to artificially restrict rather than embrace the future and all the benefits it offers.

    To me It feels as that as much as I don’t fully understand the future and implications of everyone having a say, others are afraid of it. The core message here, when stripped of the hyperbole of ‘responsible’ ‘openness’ ‘opportunity’ and ‘engagement’ is “everyone be afraid”.

    We should let it develop, not strangle it with restrictions.

    Reply
    1. amcunningham

      Re your query about info about patients and xrays- here is a post I have written with some great comments: Case discussion on Twitter: how can we make best practice explicit? http://wishfulthinkinginmedicaleducation.blogspot.co.uk/2012/06/case-discussion-on-twitter-how-can-we.html

      Reply
      1. Simon Carley (Post author)

        Thanks I have seen that before. Reading it suggests that no anonymised clinical information can ever be shared in SM spaces. That does seem rather draconian and fearful.

        The crux seems to lie in the issue of recordings made for broadcast.

        Para 37 is the interesting one. As written it is about a priori recording explicitly for broadcast. That’s not the same as using old ecgs/X-rays that were not created with that intention at the time.

        It’s still not totally clear IMHO.

        S

      2. amcunningham

        Hi Simon,

        Sorry, I missed my reply. Draconian seems to be the word of this spring! What do you think is draconian about my post? The suggestion that we don’t discuss patients online without their consent?
        Feel free to reply on the post if you don’t want to comment here,
        AM

    2. Simon Carley (Post author)

      Thanks Haider, wise words as always. I think sharing your wrist X-ray is fine under gmc regs so long as it is anonymised. If taken as part of normal care it seems to pass the confidentiality regs of gmc. In my opinion at least!

      Who would we ask if we have a question about these matters? Is there a GMC office of Social Media? Perhaps we must wait until case law finds a way through to interpret this…. Not a good solution but one that I think looms in the background.

      S

      Reply
      1. Haidar

        HI Simon

        The question arose from a site we created called Emergency Medicine Radiology Bank (ww.EMRBank.org) in 2006. It allowed registered users (free) to very quickly upload X-rays to a repository that could then be shared openly, even with unregistered users

        I even won a prize for it (Medipex innovation something or rather 2007).

        Within 3 months we had 300 users and 500 images, including normal wrist & hip images at all different ages.

        Everyone ticked a disclaimer and behaviour amongst professionals (from many countries) was impeccable. It was back then that I had the thoughts and discussions about what confidentiality is.

        No one we asked back then could wrap their head around the clear fact that all information (video, written, image, audio, whatever is just a bunch of bytes). This being given the question becomes one of identifiability (read confidentiality) and security.

        Dealing with security: My favourite quote on information security comes from the head of information security at the National Security Agency of the United States of America Deborah Plunket, who at a hacker conference in 2010 signalled:

        “There’s no such thing as ‘secure’ any more. The most sophisticated adversaries are going to go unnoticed on our networks. We have to build our systems on the assumption that adversaries will get in. We have to, again, assume that all the components of our system are not safe, and make sure we’re adjusting accordingly”

        I take this to mean we have to adjust the importance of security to the risk information conveys. We do that already, by choosing which platforms we use for various types of information.

        There is little scope for precise enough guidance on this except, as Deborah says, “to adjust accordingly” and assume everything is open. The variables are too great, use your brain.

        So there remains a question of whether these bytes of data that are all open (if someone wants them enough) are also actually identifiable and that too is also difficult.

        At one extreme if I track down a tweeter, get the date of a tweet, then get the records of all the patients someone saw in the few months before, identify the patient, tell them and hold you responsible. Then, I would suggest to you, I am both incredibly dull and devious. And you could not reasonably charge the tweeter for that.

        On the other hand if I tweet someone’s name followed by a barrage of insults relating to their medical history, you get the point…the sheer number of situations and scenarios is too great to succinctly summarise in a paragraph of guidance.

        Interestingly there is a field of law that pertains to this, that, from memory come from the states, where people started trying to sue government for holding various pieces of information in numerous databases, that, if mined and put together would constitute a breach of their privacy. Someone can call me on this.

        Anyway, back to our project:

        We donated the entire project to the College back in 2007, who call it EMI Bank and moved it to the enlightenme platform. We created some amazing interactive graphics of a Virtruvian man for them there where a few clicks could get the image you want, though I understand it has changed significantly.

        Anyway I haven’t looked at it for over 5 years now.

        In the meantime the open http://www.radiopaedia.com site has taken off in a big way, and has the sort of light touch I like about it.

        Their policy on consent appears to be “be professional, use your brain”.

        Apologies for the stupidly long reply, my fear is that people who don’t really understand the new world will pass draconian rules that inadvertently create disproportionate process and stifle innovation.

        Lets just be reasonable.

      2. Simon Carley (Post author)

        Thanks for sharing those thoughts. I share your anxieties.

        S

      3. amcunningham

        I think there is a bit of confusion about how our professional regulation works. It isn’t by statute or case law. it’s by us talking to each other about what we think the pros and cons of what we are doing is. That’s what self-regulation is about. Every now and again the GMC, and other similar bodies, will set down what they see as good practice. We then have more conversations about it and try and spot the gaps or problem areas. To me that is what being a professional is about.

  5. Roger Harris

    Does the sensitivity of the case have any bearing??? Discussing a scaphoid # might be considered differently from an STD for instance?

    Reply
    1. Simon Carley (Post author)

      I think the impact may be lesser on the patient if confidential information was revealed, but the guidance does not discriminate in terms of impact.

      If a doc were to be accused and found guilty them I suspect the severity of sentence would be affected by impact.

      S

      Reply
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  8. Simon Carley (Post author)

    Thanks Anne-Marie I think your post on the clarification from the GMC answered many of the questions raised.

    http://wishfulthinkinginmedicaleducation.blogspot.co.uk/2013/04/response-and-clarification-from-gmc-to.html

    Worth a read.

    S

    Reply

Thanks so much for following. Viva la #FOAMed

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