By Alan Regenberg

The American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB) have just issued a policy statement, “Online Medical Professionalism.” This sort of guidance is timely and needed. I appreciate their enthusiasm for online technologies as a tool with the power to “positively affect the health of communities”, and I think that encouraging ‘self-auditing’ pushes in the right direction, though, I’d encourage enhancing one’s footprint via engagement over an occasional self-google.

Unfortunately, I also think there are serious problems in how the ACP and FSMB have framed the challenges and their positions.

Let’s start with position 2: The boundaries between professional and social spheres can blur online. Physicians should keep the two spheres separate and comport themselves professionally in both.

I haven’t seen any particularly compelling evidence that the challenges of managing our lives online are very different from those we find in the world we continue to inhabit outside of online communications. Physicians (and other professionals and non-professionals and professional athletes and probably everyone) already have experience with managing their professional and personal identities/spheres. This is not new terrain, and any differences between public activities online and public activities elsewhere are trivial. So, for example, posting drunken photos or racist tweets is not meaningfully different from any other drunken, ranting, public spectacle.

The response I expect here is—wait, there it is in position 5: “But, ‘The reach of the Internet and online communications is far and often permanent…’”  This seems like a common claim in support of the uniqueness of life online.  I’m not sure if it has been empirically tested, but it’s increasingly irrelevant. Even if this claim was true, the use of smart phones, other mobile devices, and social media is near ubiquitous – meaning that activities in public are all potential content for sharing via social media through photos, videos, blog posts, SMS, tweets, etc.  So, drunken, ranting, public spectacles are increasingly likely to be witnessed both in-person and shared online.

Returning to position 2, I am convinced that the claim – physicians should keep professional and personal spheres separate – is, for all practical purposes, impossible. Putting on my low-rent, pop-philosopher hat, I’d argue that this is a problem, since, as real philosophers put it, ‘ought implies can’.

I think it’s more realistic and helpful to view professional and personal identities as existing on a continuum. It’s not that they are indistinct, but rather that they are always connected to varying degrees. Roles played by individuals can fall mostly within one sphere or another, or they can reside gray space in between.

Let’s look at Ben Carson’s recent experiences in expressing his personal/political views in a variety of venues. Starting with brief and relatively benign comments about health care reform and taxation at a prayer breakfast and continuing up through his offensively-framed and poorly-received comments about gay marriage, Carson has ‘enjoyed’ a fair amount of media attention while sharing his political views (as an aside, the ‘political’ sphere may be subsumed within the personal sphere, but I suspect it’s yet another interconnected sphere to consider in policy statements).

Carson was set to be this year’s commencement speaker for the Johns Hopkins School of Medicine. A blend of gossip, traditional and social media fueled debates about whether he should continue in this role despite his comments. Some students launched a Facebook-based petition for his removal from the program.

Hopkins tried to put an end to the controversy by releasing an apology from Ben Carson and a letter from Paul Rothman, Dean of the School of Medicine at Johns Hopkins, Rothman labels Carson’s comments as ‘offensive’ and ‘inconsistent with the culture of our institution,’ and then gets to the crux of the problem:

“Dr. Carson is well known for his accomplishments as a neurosurgeon and for his contributions to the Baltimore community. While his recent comments are inconsistent with our core values, Dr. Carson has the right to participate in public debates and media interviews and express his personal opinions on political, social and religious issues. We strongly value freedom of expression and affirm Dr. Carson’s right, as a private citizen, to state his personal views.”

Reading between the lines, I take this to say, “personal and professional spheres are different but hopelessly entangled.” And, I think the entire experience demonstrates: 1) it no longer makes any sense to separate online communication from other modes. Some of Carson’s comments were delivered at public events, some on broadcast TV. Subsequent debates them happened in person and via newspapers, tv, social media. It’s all hopelessly entangled, and 2) it is not possible to separate between professional and personal identities. Carson was expressing his personal views, yet these immediately had an impact on aspects of his professional life. It’s all hopelessly entangled.

In light of this, a better formulation of position 2 would be something like: “professional and personal spheres can never be completely separated. Physicians (and others) should keep this in mind while navigating their lives, both online and off.” Position 2 tacitly acknowledges this fact in exhorting physicians to comport themselves professionally in both spheres.

I’m not going to resist the urge to unfairly lob a few more criticisms of the new policy on my way out the door. I think position 3 is short-sighted and wrong.  While I appreciate concerns about inappropriately overextending existing technologies, I don’t see any compelling argument for why physician-patient relationships could never be established electronically. The clinical use of electronic communications should, instead, be bounded by technical capacities. Also, as a colleague helpfully pointed out, insufficient attention is paid to the challenges related to conflicts of interest. These both merit more discussion – another time, perhaps.

After all of this, I wonder if physicians might not have been better served through a simple reference to the time-tested axiom for online behavior, Wheaton’s Law.

Alan Regenberg, MBe, is the Bioethics Research Manager at the Johns Hopkins Berman Institute of Bioethics. He is currently developing and implementing strategies to use social media as a tool for broad public engagement around issues in bioethics. You can follow him  @bermaninstitute or, using his inside voice, @aregenberg.

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Alan Regenberg

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2 Responses to “Professional & Social Spheres Blur Online”

  1. Leah says:

    Wow – this post is awesome and so informative! I happen to know that Dr. Matthew DeCamp has done scholarship on this very topic of medical professionalism online; I would love to hear his perspective on these new guidelines…

  2. I’ve been talking with the Brit MDs on Twitter while they ease into this brave new internet world.

    My basic stance is that folks should not be fired for something they said on the internet- and that the public needs to understand that MDs are people too. (Having graded many, many premed exams, I am already more than aware of this fact.)

    I worked with a lot of neurosurgeons for my recent PLoS ONE on intra-operative brain tumor diagnostics( They are very nice people, with a high amount of technical expertise. However, they do have a tenancy to become more wedded to their hypothesis than they are to their data.

    The public must stop treating the poor MDs as though they were infallible gods. (The infallible gods would be the math professors, heh.) We humans are still working on evidence based medicine. We still have much to discover about the true physical models for how life works- and what makes it stop working.

    Medicine is science-based. It is not science- and there are pretty darn good reasons why the two are separated. MDs must do much lab work to earn their degrees- but this is not the same thing as performing long-term, large scale investigations into the fundamental mechanisms of the natural universe. Right now, the public seems insist that MDs do everything, which results in overworked MDs who give poor patient care.

    Please, Public: lay off the MDs; and stop trying to get them to be gods who do five different jobs all at once. It’s bad for your health!

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