Maintaining Medical Professionalism Online: Posting of Patient Information: Case History

CASE HISTORY
Ms Jones, 40 years old, with a past history of silicone augmentation mammoplasty, is diagnosed with sarcoidosis after being admitted to the hospital with a rash determined to be lupus pernio. The x-ray is classic for sarcoidosis, but the implants partially obscure the pulmonary findings; this makes the radiographic diagnosis more challenging. Dr White, an internal medicine resident who had rounded on Ms Jones, wants to submit a clinical vignette to the American College of Physicians (ACP) regional meeting if others think this is a good case. Dr White downloads the photo of the rash and the x-ray.
To test out the case, Dr White posts the photo of the rash, history, and test results on his Facebook page. Using the caption “What’s the diagnosis?” he tags names of medical school friends and colleagues so that when they log on they are taken to the photo and other information. He reasons that this is okay because of the absence of personal information about the patient, such as name and age. When 2 colleagues make the correct diagnosis, he congratulates them and posts the x-ray as well, which elicits many comments, including comments about the breast implants. A faculty preceptor at his institution sees the postings and wonders whether she should notify the program director.
COMMENTARY
Cases such as the above scenario raise ethical questions about patient privacy and confidentiality, as well as the moral development of physicians. Some might argue that because Dr White omitted individually identifiable information about the patient that there is no breach of ethics and professionalism. Others might wonder whether Dr White’s avoiding unique identifiers constitutes sufficient due diligence. Some might reason that showing breast images in the “public” space of Facebook is never a good idea and is somehow unseemly and shows that Dr White lacks judgment. Bottom line: it appears that Ms Jones did not give authorization to have her picture and information used outside of her care setting.
The simplest interpretation of this case is that a seemingly well-intentioned resident posted a clinical case to a public social media site but did so without the patient’s consent. Cases such as this raise broader questions about the appropriate ethical constraints for using patient-specific information for nonclinical purposes. Must all uses of any patient clinical information require consent, even if no identifying information is being disclosed? If the information had been merely a complete blood cell count and a biopsy image, would we still require consent? Would blanket consent in an explicitly clinical teaching setting for use of any clinical information for teaching purposes constitute sufficient authorization, or is “instance-specific” consent required if images are used? Is Dr White’s use a legitimate teaching purpose?
The medium used makes this case ethically problematic. Facebook is a public site that often spans individuals’ professional and personal lives. Even if one maintains a personal and a separate professional persona, as ACP and others recommend, Facebook is a public space and patient information and images are downloadable and control cannot be maintained. The recently published ACP and Federation of State Medical Boards guidance on online professionalism highlights the risks and benefits of using online media particularly when it comes to privacy and confidentiality.[1] Privacy refers to a person’s right to not be intruded on against his or her wishes. In medicine this commitment is based on respect for persons and autonomy as well as the duty of nonmaleficence. Confidentiality refers to how information will be handled.[2]Maintaining it fosters trust and allows patients to be open in their encounters with clinicians. Both are subject to state and federal law, especially regarding personal health information.[3,4] The ACP Ethics Manualstates:
To uphold professionalism and protect patient privacy, clinicians should limit discussion of patients and patient care issues to professional encounters. Discussion of patients by professional staff in public places, such as elevators or cafeterias, violates confidentiality and is unethical. Outside of an educational setting, discussion of patients with or near persons who are not involved in the care of those patients impairs the public’s trust and confidence in the medical profession.”[5]
By extension, posting and facilitating a discussion of a case on Facebook is more like talking in a public place than in an educational setting. Strictly speaking, if identifiers are removed for a true educational use, there is no HIPAA or HITECH violation.[3,4] However, even if her identity is not disclosed, Dr White should not be broadcasting the case in this setting. In contrast, if the case information Dr White had posted was used in a more explicitly educational venue such as morning report (which could bring benefit to the patient) or on a poster at an ACP meeting, those differences might change the interpretation. Had Dr White posted to a secure, physician-only educational site that had specific, time-limited image-used discarding procedures, that would at least show a degree of due diligence. Social media sites designed with the intention of promoting physicians’ learning from one another have emerged in recent years, some with stated de-identification requirements and security restrictions and which encourage patient consent.[6] Dr White’s actions and failure to obtain consent here, however, would still be problematic.
Although no individually identifying information was disclosed, obtaining consent before posting would be strongly advisable. Information should only be used in a true educational context. “Confidentiality is a matter of respecting the privacy of patients, encouraging them to seek medical care and discuss their problems candidly, and preventing discrimination on the basis of their medical conditions. The physician should not release a patient’s personal medical information (often termed a ‘privileged communication’) without that patient’s consent.”[5] This quote illustrates a key issue for use of social media in health care. Maintaining long-term trust in the profession, as well as trust in the individual patient-physician relationship, binds physicians to higher standards of behavior than the general public. Dr White should have obtained consent to use Ms Jones’ clinical information in a legitimate educational setting. If consent was not obtained, it should have been. Having the discussion and obtaining authorization represent a level of respect for patient autonomy and privacy that physicians at all stages of learning should demonstrate. Doing so might also have clarified for Dr White that the “educational” method he was planning was not so educational and was inappropriate.
Professionalism involves both abiding by existing standards of behavior but also instilling judgment about maintaining trust in the profession as a whole. Dr White’s motives in posting the case were seemingly benign. However, Dr White may not have exercised sufficient forethought about how his posting behaviors might be interpreted by others. Does Dr White have the capacity to discern when downloading images or posting information might just be unwise? Should the faculty preceptor notify the program director? There is legitimate variability in how physicians and program directors might respond to such behavior. Dr White is a trainee struggling to learn and grow as a professional — a process that requires meeting both behavioral expectations and cultivating the discernment and discretion to become a trusted professional. Documenting the behavior could help prevent future occurrences and ensure institutional memory. The overall intention of the resident’s posting was not malicious. This incident presents a teaching opportunity for the preceptor to discuss the intent and suitability of the post with the resident, to see if he understood why his behavior was inappropriate, and to learn and grow. At a minimum, a discussion should occur between the preceptor and the resident and should be documented in an evaluation. If the behavior persists, the program director should be notified.
Dealing with the realities of social media, online medical training, and the subtle social meanings associated with body images in the 21st century will not go away. Obtaining consent for use of clinical information is not burdensome and should be included in training; it reinforces the traits that engender trust and are needed to promote lifelong development of professional character. The hard task of becoming a professional requires developing the instincts, judgment, and desire to figure out not just what is permissible but what is best.

REFERENCES

  1. Farnan JM, Sulmasy LS, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM; for the American College of Physicians Ethics, Professionalism, and Human Rights Committee; the American College of Physicians Council of Associates; and the Federation of State Medical Boards Special Committee on Ethics and Professionalism. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158:620-627.
  2. Kuhn TM, Barr MS, Snyder L; for the Medical Informatics Subcommittee and the Medical Informatics Committee of the American College of Physicians (ACP). 2011. Health information technology and privacy. Philadelphia, PA; American College of Physicians; 2011: Position Paper.https://www.acponline.org/advocacy/current_policy_papers/assets/hit_privacy.pdf. Accessed October 31, 2015.
  3. HIPAA Privacy Rule, 45 C.F.R. Parts 160 and 164 (2013).
  4. Health Information Technology for Economic and Clinical Health (HITECH) Act. ARRA Components–January 6, 2009. http://www.hipaasurvivalguide.com/hitech-act-text.php. Accessed October 31, 2015.
  5. Snyder L; for the American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: Sixth Edition. Ann Intern Med. 2012;156:73-104.https://www.acponline.org/running_practice/ethics/manual/manual6th.htm orhttp://annals.org/article.aspx?articleid=1033289. Accessed November 17, 2015.
  6. Figure 1, Inc. Terms of Service. 2015. https://figure1.com/sections/tos/. Accessed November 17, 2015.

 

Source: Medscape Pharmacist

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