Sanitized for your protection

There’s a growing movement to persuade us that medical blogs need to be regulated for our safety and protection. A paper published in this month’s online edition of the Journal of Internal Medicine has been the source of recent news stories, stating that blogs written by medical professionals pose a threat to patient privacy. But the larger claim is that the information could threaten the integrity of the health field and that professional organizations need to set standards for what is appropriate tone and content.

The news release about this new study and the resultant syndicated news stories over the past week have painted medical blogs in a fairly negative light. Today, the Chicago Tribune joined in and described medical blogs, not as being written by professionals behaving ethically and responsibly, but as “a growing circus of blogs” similar to the Wild West. Unlike the ritual of medical educational Grand Rounds, steeped in formality and tradition, where “young physicians learn to accept their elders’ old-school admonishments with reverence and humility,” Grand Rounds on the Internet were unflatteringly described as “part classroom, part locker room, part group therapy and part office party—a free-wheeling collection of rants, shoptalk, case studies and learned commentary (along with the occasional recipe, movie review or vacation slide show).”

The lead author of the article in the Journal of Internal Medicine calling for restrictions, Dr. Tara Lagu, M.D., MPH, with the Robert Wood Johnson Clinical Scholars Program, was quoted as saying: “It's time for us to take some responsibility and really think of how we can maintain the integrity of this process.” [The “us” wasn’t defined.] Some bloggers are using their blogs to blow off steam, report interesting studies or share experiences in medicine, she said, but others “make forays into the political realm of healthcare policy.” Only a few, “including one sponsored by the highly respected Cleveland Clinic,” she said, “are primarily teaching tools.” [Cleveland Clinic posts: here, here and here.]

These news stories received sharp criticism from one doctor blogger who objected to portrayals of medical bloggers as not concerned with professional integrity. Certainly, there are a fair number of culpable medical bloggers, some not even medical professionals, who are paid by social marketing media companies or various companies, and blur the lines between marketing and editorial. But these and other ethical issues have not gone unrecognized by health professionals concerned about the integrity of medical blogging and who have come together to provide ethical standards. As pediatrician Dr. Gwenn wrote, while there are no official standards, there are codes being created, such as the Healthcare Blogger Code of Ethics. While no system is perfect, through this peer-review process medical bloggers and patient advocacy bloggers’ credentials are verified, as well as their adherence to disclosure of conflicts of interest, patient confidentiality, courtesy, and efforts to not cause harm and present information accurately, citing sources when possible.

Years before the pharmaceutical and healthcare industries and social marketing took an interest in blogging to dominate much of it, Matthew Herper at Forbes described the best medical blogs written by doctors, scientists and other health care professionals, as “shockingly good, providing riveting reading about how people are diagnosed, treated and sometimes cured.” As he wrote:

The complaints of the average Dr. Blogger reveal similar concerns: that big pharmaceutical firms are pressuring patients to take expensive drugs that aren't needed, that medical malpractice insurance is increasingly pricey, and that trial lawyers will take them for all they have. Moreover, some laboratory scientists have gotten into the act, talking in detail about how drugs are developed and whether new technologies will work. Many bloggers name names, criticizing or praising big drug firms.

The best medical blogs continue to provide content that can exceed the quality and range of viewpoints found in mainstream media, and medical bloggers regularly investigate and break stories that find their way to popular discourse. And, as this month’s Journal article also noted, lawyers and pressures from those they criticize have led a number of medical bloggers over recent years to discontinue their blogs to preserve careers and livelihoods. Still, there are more than 70 million blogs tracked by Technorati, with about 120,000 new blogs created every day. Even RWJF has a blog today.

This study, funded by Robert Wood Johnson Foundation, sought to determine the extent of medical blogs who “displayed a lack of professionalism” or who commented about patients and could potentially violate their privacy. They searched through three aggregators (Medlogs, Yahoo Health and Medicine Blogs, and The Medical Blog Network) and identified 271 blogs written by doctors or nurses who had written at least one health-related post in 2006. Interactions with patients were described in 16.6% of the blogs, with three having shown photos that could identify a patient. Of these, the authors found examples where almost one in seven had described patients positively and 17.7% described them negatively. About half of the medical bloggers discussed the healthcare system and 40% talked about the health profession, with 30% having made a negative comment about some aspect. The authors found that 11.4% of blogs promoted products or advocacy without disclosing conflicts of interest.

[No evidence was provided to compare these statistics with those in mainstream venues.]

In their discussion, Dr. Lagu and colleagues said that medical blogs have a growing importance in medical media — which includes the professional literature, medical stories and dramatizations, books, movies, theater, radio and television — but differ from traditional venues in that “any person with Internet access can author a blog.” Because bloggers are not subjected to the editorial process, they said, “blog authors have few incentives to maintain their credibility and integrity or, in contrast, to compromise it for the sake of ratings or sales.”

[Medical professionals, readers are to believe, put aside their professional integrity when they take off their scrubs. No evidence was provided comparing the professional qualifications of medical bloggers to mainstream health reporters. No mention was made that many medical bloggers are more qualified to comment on health issues than most mainstream reporters who are not licensed medical professionals or even hold degrees in science or medicine. No evidence was provided to support claims that most medical bloggers were generating any revenue from their writing — let alone more than mainstream health reporters and medical writers — or were corrupt.] The authors went on to say:

Second, medical blogs are part of the public face of medicine. Whether or not blog authors are genuinely members of the health professions, they represent themselves as such and are likely to be seen as such. Most medical literature is subject to rigorous peer review and typically reaches only internal audiences. Other forms of medical communication, such as presentations at medical conferences or articles in the lay press, adhere to specific standards of content and decorum. In contrast, medical blogs are public documents written in a diary style typically used for private thoughts. The authors of some medical blogs censor their thoughts and comments less than we expect they would in traditional public settings.

Third, medical blogs derive their credibility from their relationship to the health professions, and therefore reflect on these fields... some blogs include unprofessional tone or content, such as negative comments about patients or the profession, violations of patient privacy, or promotion of special interests.

But the RWJF authors did note their approval of medical blogs that can provide a new route for “communicating substantial, evidence-based health information to the public,” who emphasize positive elements in the practice of healthcare, and maintain confidentiality and a respectful tone. Dr. Lagu and co-authors noted that self-regulatory efforts, such as the Healthcare Blogger Code of Ethics, are key to maintaining professionalism and trust. They also noted that medical blogs can give voices to clinicians whose points of view might not otherwise reach an audience, and that having a venue to talk and reach out for peer support could help improve retention of healthcare professionals. But in the end, they wrote that:

They also risk exposing the public to unprofessional content and tone, privacy violations, and hidden promotions that damage the integrity of the medical field... Although there has been some discussion in the lay press regarding the ethical questions posed by medical blogs, there has been no organized or official response from the medical profession.... professional organizations should provide standards for blog tone and content... which would encourage health professionals to respect their patients and their profession in their writing... and the place of this new medium within norms of medical professionalism.

The internet could be said to be the largest democratic forum in our history and it brings together people, information and ideas from around the world. It’s a public space where citizens can discuss and comment about anything, educate and learn, opine, entertain and even be human, with all the foibles that entails. Unlike mainstream publications, on the blogosphere you can find any and all sides of an issue you care to read. Unless you are a blogger in China. [See all of the FAQs at GreatFireWallofChina.org for the latest news.]

Do we really want medical blogs to undergo review and regulation to ensure their adherence to approved content and tone, in keeping with traditional medical communications? Do we really want content and comments examined and anything controversial or that might be seen as critical or negative about the industry to be censored? Is this really about protecting consumers or the interests of healthcare stakeholders? Are medical bloggers really such a threat to public health and safety?