Medblogsphere And Confidentiality

The truth is there is an epidemic explosion of doctors who blog, showing to the public that physicians are not robotic and cold. That their heart beat just as passionately as the rest of humanity. That the logistics of their work is not just about doing the best for their patients (unfortunately), but they also must deal with excruciating paperwork, sound or unsound hospital policy, budget cuts, (nice or annoying) superior’s instructions despite what they think is best for their patients, and the list goes on.

I am not at the stage where I have to worry about making hospital or departmental policies, but when the policies are made, they do affect the quality of my work. (what investigations I can order for case work up, whether I can admit my patients into the ward or not, what meds I can prescribe)

What you said you wanted to do when you said you wanted to become a doctor (to help people, to make a difference, to save lives), you said all that without reading all the fine prints that came with the contract of being a doctor. Life is not so flowery when you cast away your rose-tinted glasses, alas.

If you are a frequent blog reader and are familiar with blogger doctors all over the world, you will notice that there are SO MANY doctors who blog but at the same time there are just not enough ethical guidelines regarding what you can write and cannot write in your blog. This is still a grey area that must be carefully manoeuvred… but nothing an experienced blogger can’t handle.

I began this blog when I was a medical student in 2009. So many years ago! Even then, I had already researched about what I could write, what I shouldn’t write at all and how to manoeuvre and manipulate the matter so that even if I write something that is borderline forbidden, I can still get away with it. I might get in some trouble, but nothing anyone can really pin down to make a case. I know my way around med blogging. So whenever people express concern about doctors writing about their cases in the blog, I just take note of their concerns but still continue to do my thing. Because I know my way around medblogsphere. I would never do something risky without a potential exit plan. (but I humbly admit that sometimes exit plan can have loopholes… but nothing that a good lawyer cannot rectify).

I know how to write about cases so that no one can identify my patient, not even my own colleagues. And not even the patient will know it.

I have written about Mrs. H once. But her name doesn’t start with H.

I said that Mrs. H went to KL after her divorce. But that wasn’t where she went. 

I said she had a son with a previous marriage. But how many previous marriages did she have? Or she might actually have a daughter.  Or she might actually have more than one children. See?

I said that Mrs. H has to sell sandwiches to support herself. But in reality, she might have never sold a single sandwich in her whole life, but perhaps she sold something else…. or even had another job altogether, say, a cleaner. 

If the Mrs. H (whose name doesn’t start with H) were to read my post, she wouldn’t even be able to recognize herself. Because as a doctor, I am only concerned about the main lesson/point in her life story that I can share with my readers. But in other aspects of her story,  I am like a writer who is given free reign to manipulate all her personal information, from how she looks (whether she is beautiful, whether she wears a hijab or not, whether she has any scars or personal defects) and her personal information (her age, her race, her job, her other illnesses, who her husband is, how many children she has) and her general characterization.

It’s like writing a short story or even a novel.

A good writer KNOWS that plots do not vary much. You read a few variations of each genre once, then you have read them all. (that’s why we have genres. Boy meets girl and falls in love – that is romance. The plots won’t vary that much. Good guy defeating the crazy villain – that is mystery/thriller. A vampire collaborating with a demon to create a high-tech powerful device to conquer the world- that is paranormal sci-fi.  Most plots, depending on their genres, are always the same. Over and over again. Any reader KNOWS that).

So a good writer knows that a good book MUST have great characterizations to counter the overly-used plots, so that the readers would love the characters themselves, even though the plot is same old, same old. A good writer would invest a lot of time to create a good characterization if he/she is smart.

So let’s go back to Mrs. H.

Mrs. H, if she ever comes across my blog, would NEVER be able to say in absolute certainty that “That’s me! That’s me the doctor had written about!”. 

But she might recognize the main plot of her story “a woman who was tricked into marrying an elderly man whose family wanted a free maid and financial provider for their aging father”. But how many people in this world have been in the same ‘story’ as she? Legions! She would most likely end up saying, “Wow, looks like I am not the only one in this world who suffers through the same thing. There are other patients like me.”

In the VERY unlikely event that she were to sue me, she would end up paying my legal fees when I win the case!

This is just an example of what I meant by knowing your way around medblogsphere. You have to manipulate the characterization of your case. We are only interested in the main lesson and take home messages from a certain case. Readers don’t care about the details of the patient’s character. So, use that to your advantage. Purposefully disguise your character without compromising the actual point/lessons of the case. Then, you should be reasonably safe.

Another important aspect of knowing your way around medblogsphere is to know how to use disclaimers! This is so important! Once you put a disclaimer, you are also reasonably safe. I have an existing general disclaimer for the whole blog from the day I started working in MOH (you can scroll  down and find the disclaimer at the bottom of your right hand side) and also for each specific post that I think requires an additional disclaimer.

Below is an example of my own disclaimer which has been standing for the past seven years.

“Afiza Azmee is an individual, and My Life Poetries That May Not Rhyme is a personal blog. The opinions expressed here are the author’s product of her thinking process. And they do not represent the thoughts or opinions of anyone related to the author and especially NOT the author’s employers (the ministry of health).

The information in this blog is provided ‘as is’ with no warranties and confers no rights. Please use your discretion before taking any decisions based on the information in this blog. Author will not compensate you in any way whatsoever if you ever happen to suffer a loss/ inconvenience/ damage because of/while making use of information in this blog.

Author reserves her rights to a change of opinion in the future. She is, after all, an open-minded person.

All images in this blog, unless stated otherwise, are courtesy of Google Images. Thank you, Google.

Author welcomes your comments, your disagreements, your views about any of her posts in this blog. But she reserves her rights to delete those that contained profanities, vulgarities, unrelated topics, and annoying anonymity.”

I subscribed to Psychiatric Times which is a very reputable online magazine for psychiatrists in the US. The doctors there write about their cases all the time. One example is given in this link below. The title of the post is ‘A coin flip’. To read the case, you can click H.E.R.E  

http://www.psychiatrictimes.com/residents-corner/coin-flip

The famous Kevin M.D blog also writes about cases frequently. The blog has even more tips about how to write on clinical cases, which PROVES that writing about your case is not absolutely forbidden. You just must know how to do it right. If you want to read the tips, you may click the link H.E.R.E

http://www.kevinmd.com/blog/2011/09/doctors-write-clinical-cases-online.html

When I was a HO, I had written about one particular case, disguising the character and the patient as I have always done since I was in medical school. A doctor wrote in the comment section that “I shouldn’t be writing about cases. Not even for educational purposes due to confidentiality issues.” I knew she was an MO in the same hospital as I and at that time my blog was viralled because of something I had written against a particular department in my hospital when I was a HO. She meant to reprimand me in her comment but I knew what I was doing. Like I said, I learned ethics thoroughly. I may not always be professional in what I said, wrote or did as an MO, but there is ALWAYS poetic justice behind every action I took. Someone must have crossed my boundaries and my principles, causing me to snap and when that happened, I wouldn’t answer about what I am capable of doing. So I replied by saying “Based on what I have written in this post, why don’t you track her down, find out who she is and locate her, and then get her to sue me for breaking confidentiality. I’ll wait.”

She never replied to that comment. Perhaps, because she never bothered to track the patient. Or perhaps because even if she wanted to track the patient, the patient would be untraceable.

We CAN write about cases. If cases can’t be discussed even for educational purposes, how would lecturers teach medical students? 

Sometimes a patient talks to you specifically about her situation, without knowing that you will be discussing the case with your specialists or even with your other colleagues later in the day… is that okay?

For example, most of us have not told our patients, “Kes awak nanti, kami akan discuss dalam meeting pagi-pagi. Dalam meeting tu ada student nurses, student MAs, student doctors etc etc.”

Remember, these students are not even our own staff… they are students who do not actually see the cases themselves but come to know about all those cases when they are discussed in meetings/audits/mortality reviews.

So, ARE cases allowed to be discussed for educational purposes? Yes! And also… No! Depending on the situation and how the case was discussed or written.

So the MO who had written the comment of how ‘cases are not allowed to be discussed even for educational purposes’, was just plain wrong.

You cannot give such a blanket statement over this matter. This issue is rich in nuances and must be treated and analyzed in a case-by-case basis. Otherwise, we will be contradicting our principles with our own actions when such a blanket statement is given.

Regarding cases discussed in blogs, there was never a clear black-and-white guidelines about it other than making sure that identifying information are not included and discriminating information are edited! That is the only important rule! The rest are carefully manoeuvred, again, on a case-by-case basis. For example, if the case is high profiled and well-known, just changing the identifying details may not even be enough… so, you must improvise even more.

Again, I suggest to read Kevin M.D blog post from the link I provided above, regarding how to go about editing identifying information.

***

I have heard of stories of how some master students who suffer from depression were so betrayed by their supervisors when their conditions were revealed to other lecturers and then their whole batch found out about it! And things like these happened in the academic setting of our own medical university!

Confidentiality ke laut!

How about housemen? When I was a HO, I found out from another HO that there was this particular HO who was under psychiatric follow up! Apparently, somehow, words got around. But how?

Maybe confidentiality is only preserved for hotshot specialists or only applies for HODs or ‘orang ternama and berpangkat’. But, perhaps not for the HOs? Once a HO (or a university trainee) is diagnosed of some mental disorder, somehow it is okay if their cases are discussed around?

If you are in Australia, the trainee could sue her supervisor! But in Malaysia, you don’t do that unless you want to fail your master program. Hahha.

For aspiring medbloggers out there, don’t worry if you want to start a blog to record the journey of your career as a doctor or simply to vent about your daily grievances in general. This has been going on for years in the West and Malaysians are catching up so admirably in this aspect of medical culture. Internet and social media are such an integral part of our everyday lives and it does not show any signs of fading. Older generations who are not internet-savvy have either retired or retiring. In fact, even older physicians who were not born as Gen-Ys (non-millennials older doctors) do have a blog. By the time internet-savvy doctor-bloggers become specialists and HODs, blogging doctors would be mushrooming all over the place.

This phenomenon cannot be stopped. It can only be regulated.

You just have to know the ropes and the absolute do’s and dont’s. The rest are in the realm of the grey areas. Just employ your creativity to disguise the details of your cases and make sure your disclaimer is well-written.

Good luck!