A concerned friend sent me a link to a story about a doctor who had posted details of a trauma case on Facebook. Apparently the details were very specific, and a non-doctor Facebook friend was able to easily identify the patient. The doctor was fired from her job, disciplined and fined by the State Medical Board.

The lead-in queries: “Facebook is a great place to unload after a long day at work. But what if you work in an emergency room, where privacy is paramount? And what if the thing you want to discuss is not the evening traffic or a grumpy colleague but your patients?”

http://www.boston.com/lifestyle/health/articles/2011/04/20/for_doctors_social_media_a_tricky_case/?p1=News_links

In the article, various and sundry experts are interviewed, and the general consensus seems to be: Don’t write about your patients.

Obviously, this subject touches me and what I do pretty deeply.

Now, I’ve given alot of thought to respecting patient confidentiality, for many reasons, ethical and legal.  But here is the specter of being fired, disciplined, fined, and humiliated for the posts that appear on these pages.

It would be easier, in theory,  to shut down this blog and walk away. But for some reason, since the dawn of my medical training, I’ve been driven to write. For goodness’ sake, I’m a working mother with an infant, and I still can’t go to bed until I’ve written something. The overwhelming need to reflect, process, create, and share… only another writer understands this compulsion, I suspect.

I was particularly struck by this quote from William Carlos Williams, iconic and revered poet-physician, a man who devoted his life to treating the poor:

“Five minutes, ten minutes, can always be found. I had my typewriter in my office desk. All I needed to do was pull up the leaf to which it was fashioned and I was ready to go. I worked at top speed. If a patient came in at the door while I was in the middle of a sentence, bang would go the machine–I was a physician. When the patient left, up would come the machine. My head developed a technique: something growing inside me demanded reaping. It had to be attended to. Finally, after eleven at night, when the last patient had been put to bed, I could always find the time to bang out ten or twelve pages. In fact, I couldn’t rest until I had freed my mind from the obsessions which had been tormenting me all day. Cleansed of that torment, having scribbled, I could rest.”

What he describes sounds like OCD. Is that all this is, a whole genre of literature, legions of blogs… a kind of mental illness?

But, wait. There is merit to the doctor’s scribbling that goes beyond complusion. There is a large body of literature in the medical education journals showing the value of reflective writing in medical education… and doctors never stop learning. Reflecting on our clinical experiences, writing about them, and sharing that writing, are well-proven methods to creating more humanistic and empathetic  medical professionals. I’ll spare you the details, but I was really into this line of research, prior to being just a plain old primary care clinician.  (See references 1-21 below. ) Writing can serve a greater purpose, a purpose that benefits our patients.

So, I will continue to write, as I have. I am not interested in “juicy details”, in recounting drama or describing bloody gorey medical stuff. But I know when a case has touched me, and I am confident that I can express that deeper message, without divulging unnecessary patient identifiers.

So how to accomplish this in practice? I think the key is to stay true to the larger issue, the core theme that was touching in the first place, and change everything else.

I am wary, of course. My family’s well-being hangs in a balance of sorts here.  What if? What if a patient reads something I have written and feels they can identify themselves, and reports me to my own hospital? Have I done enough to both protect and serve as well as reflect and share?

I’m curious what others think about this….

And by the way, those references:
1. Bolton G. Stories at work: Reflective writing for practitioners. Lancet 1999; 354:243-245

2. Rabow MW, McPhee SJ. Doctoring to heal. West J Med 2001; 174(1):66-69

3. Beylefeld AA, Nena KD, Prinsloo EAM.  Influence of community experiences on first-year medical students’ reflective writing. Med Teach 2005; 27(2):150-154

4. Levine RB, Kern DE, Wright SM. The impact of prompted narrative writing during internship on reflective practice: a qualitative study. Adv Health Sci Educ Theory Pract 2008;13: 723-733

5. Charon R. Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA 2001, 286(15):1897-902

6. Anderson R; Schiedermayer D. The Art of Medicine Through the Humanities: An Overview of a One-Month Humanities Elective for Fourth Year Students. Med Educ 2003; 37:560-562

7. Hatem D and Ferrara E. Becoming a doctor: Fostering human caregivers through creative writing. Patient Educ Couns 2001; 45:13-22

8. DasGupta S and Charon R. Personal Illness Narratives: Using Reflective Writing to Teach Empathy. Acad Med 2004; 79:351-356

9. Reisman AB, Hansen H, Rastegar A. The Craft of Writing: A Physician-Writer’s Workshop for Resident Physicians. J Gen Intern Med 2006; 21:1109-1111

10. Plack MM, Driscoll M, Marquez M, Cuppernull L, Maring J, Greenberg L. Assessing Reflective writing on a pediatric clerkship using a modified Bloom’s Taxonomy. Ambul Pediatr 2007; 7(4):285- 291

11. Pearson AS, McTigue MP, Tarpley JL. Narrative medicine in surgical education. J Surg Educ 2008; 65(2):99-100

12. Shapiro J and Lee D. A Comparison of Medical Students’ Written Expressions of Emotion and Coping and Standardized Patients’ Ratings of Student Professionalism and Communication Skills. Med Teach 2004; 26(8):733-5

13. Baernstein A and Fryer-Edwards K. Promoting Reflection on Professionalism: A Comparison Trial of Educational Interventions for Medical Students. Acad Med 2003; 78(7):742-747

14. Mann, K., Gordon, J., MacLeod, A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract Nov 2007 (epub ahead of print)

15. Haq C, Steele DJ, Marchand L, Seibert C, Brody D. Integrating the Art and Science of Medical Practice: Innovations in Teaching Medical Communication Skills. Fam Med 2004; 36s: 43-50

16. Wong K, Kember D, Chung L, Yan L. Assessing the level of student reflection from reflective journals. J Adv Nurs1995; 22: 48-57

17. Pitkala KH and Mantyranta T. Feelings related to first patient experiences in medical school: A qualitative study on students’ personal portfolios. Patient Educ Couns 2004; 54(2): 171-177

18. Koepke Y. Some lessons on Reflective practice in medical education. Patient Educ Couns 2009; in press

19. Ghaye T.  Is Reflective Practice Ethical? Reflective Practice 2007; 8(2):151-162

20. Branch WT. Use of critical incident reports in medical education: A perspective. J Gen Intern Med 2005; 20:1063-1067

21. Brady DW, Corbie-Smith G, Branch WT. “What’s important to you?”: The use of narratives to promote self-reflection and to understand the experiences of medical residents. Annals of Internal Medicine 2002; 137(3): 220-223