Public Lives of Doctors?

Social media has made our private life public. Facebook, Instagram, even WhatsApp (through stories) thrive on users generating engaging content. Often this content is snaps from daily life. A picture is worth a thousand words, yet can be generated in a second. Image centered social media platforms rely on this to keep themselves going.

What about doctors (and other professionals) on social media? Is it any different for them? Should it be any different?

This post has been triggered by the #MedBikini hashtag. Here's one tweet that reveals what happened:

This journal article considers social media posts where MDs hold alcohol, wear inappropriate attire, and give opinion on controversial social topics as “potentially unprofessional.” How would any of these adversely affect the care we give to patients? 😳 #MedBikini pic.twitter.com/G1iBuqtX8n

— Ronnie Baticulon (@ronibats) July 24, 2020

I will not spend a lot of time discussing this particular paper or the twitter response to it. But I will discuss sections from two of the references in this paper.

A council set up by American Medical Association to address the subject of Professionalism in the Use of Social Media, included this paragraph in their report:

Though there are some clear-cut lapses in professionalism that can and have been made online by physicians (such as violations of patient privacy or confidentiality, or photos of illegal drug use), there are many more situations that fall into a grey area.  Examples include photographs posted online of an inebriated physician, or sexually suggestive material, or the use of offensive language in a blog.  Any of these actions or behaviors would be considered inappropriate in the hospital, clinic, office, or other setting in which a physician is interacting with patients or other health care professionals in a professional manner.  However, whether physicians must maintain the same standards of conduct in how they present themselves outside the work environment is a more open question.  Physicians certainly have the right to have private lives and relationships in which they can express themselves freely, but they must also be mindful that their patients and the public see them first and foremost as professionals rather than private individuals and view physician conduct through the lens of their expectations about how an esteemed member of the community should behave.  Thus physicians must weigh the potential harms that may arise from presenting anything other than a professional presence on the Internet against the benefits of social interactions online.

It is this particular paragraph that have been used when creating criteria for "potentially unprofessional" things in papers that followed. One of them has a section like this:

Within the clearly unprofessional group, binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act violations were the most commonly found variables. Examples of binge drinking included pictures of residents lining up 5 pints of beer in front of 1 dinner plate, doing “keg stands,”and making comments about being drunk or hungover. Examples of sexually suggestive photos included simulated oral sex, female residents in bikinis with hands pointing to their breasts, and a female resident simulating intercourse with a large cannon. Profanity was also encountered, as was a link to a racist cartoon.

Within the “potentially unprofessional” group, pictures of residents with alcoholic drinks in their hands were the most frequently encountered. There were also several polarizing political and religious comments made by residents, and 2 instances of residents holding a gun while hunting

We get a better picture (pun intended) here of what these papers are trying to hint. With that in the background let me talk about a couple of things from my professional life that I've thought quite a bit about.

Alcohol

Alcohol is a controversial topic among doctors (because many doctors consume alcohol). I do not consume alcohol. I actively dissuade people from consuming alcohol. You could call me anti-alcohol. I have certainly been influenced by Dr Dharav Shah's campaign against alcohol and his argument for why we should create a negative attitude towards alcohol (the way we have towards smoking) is convincing. And I consider it hypocritical for doctors to be consuming alcohol.

There are plenty of doctors who disagree. Some of them are of the opinion that social drinking is not a problem at all. They want to draw a line between alcoholism and social drinking and want to allow social drinking without it progressing to alcohol dependence.

There are some doctors who agree that alcohol is indeed dangerous, but do not agree with the idea that it is hypocritical for doctors to be consuming alcohol while asking their patients to abstain. This is a very important argument.

One part of the argument is that what doctors, as professionals, give out as advice in a professional setting is not applicable to doctors themselves. That I can talk to my patient about the importance of not eating rice excessively while still eating two full biriyanis a day. That professionals need not hold themselves to the standard that they're prescribing for their clients.

The other part of the argument is that what doctors do in their private lives should not be dictated by their profession. Superficially it makes sense. But does it stand scrutiny?

Firstly, does private life stay private? As we noted in the case of social media above, the notion of a private life that is wholly disconnected from public life is Utopian. What happens when something a doctor does in their private life becomes public?

Secondly, would you apply that logic when what the doctor does in their private life is something that you find morally reprehensible? Say the doctor in their private life engages in adultery, directing pornography, or working for BJP's IT cell (not that I find all of these morally reprehensible). Would you be comfortable saying "it is their private life?"

This leads to the other thing that I am constantly thinking about.

The impression that a doctor "should" make

How should a doctor appear in front of their patients?

The trouble starts from the first day of medical school. There is a certain way you're expected to be dressing. There is a "smart" appearance dictated by the higher-ups in the hierarchy which usually included (for me) shaved face, short hair well combed, clean new aprons, polished shoes, and so on.

It goes deeper. In "Be the Doctor Each Patient Needs", Hans Duvefelt tells this:

"Doctors are performers, not only when we perform procedures, but also when we deliver a diagnosis or some guidance."

The point Dr Duvefelt makes is about the therapeutic effect of a doctor-patient relationship. As a doctor, you need your patient to believe in you and in turn your advice. I talked about how this complicates everything about the doctor-patient relationship in my post about consultation fees.

The gist of the matter is that doctors might have to do things (like shaving their naturally growing beard) to appeal to the completely irrational gut-sense of their patients. Weird argument, right? I don't like it either.

I don't like it that I have to feign confidence in what I'm saying even when the field of medicine is not 100% sure about anything. I don't like it that the biases that patients make up based on the impression I leave influence their adherence to the treatment regimen I prescribe. But these are how humans think and act.

This is exactly why people dress well for an interview. Why politicians are careful about how they're being photographed. Why celebrities have a link with fashion. And why people put their degrees on their Twitter and LinkedIn handle.

I hate this world.

Unprofessional

Last day a patient messaged me. On SMS and on Telegram. My telegram bio includes pictures of me from a long time back and also a link to my telegram channel where I post links to my own blog posts. For some reason I responded to the patient on SMS although it was easier to talk on Telegram. I am not sure what to think about it. But at that moment I was not feeling comfortable with using Telegram to talk to a patient. The reason is that I blog mostly about technology. And multiple times in the past have people assumed I know very little medicine when they find out how much I know about technology. I don't want my patients to read my blogs.

That brings us back to professionalism. Professionalism is defined by society's sense of morality. And that is where bikini pictures appear potentially unprofessional and sexually suggestive images appear clearly unprofessional to some. The #MedBikini hashtag is either about stating that private lives of doctors should not matter to patients or about the idea that bikinis are not immoral, or both.

I think the entire post has been devoted to the point about whether we should worry about what patients think about us or not.

The morality of underwear pictures is something that deserves a detailed debate. I end with the following question. Are sexually suggestive images unprofessional? Why?