Anonymity, Pseudonymity, Privacy, Online Discussions, Deleting Posted Material, & Tempest in a Tweet-cup,

 

(Disclosure: I am not a physician or engaged in any aspect of health care, other than being a patient.)

Update 5/30/2011 mommy_Doctor is no longer on twitter and her tweets have been removed. I think this is a sad and sorry outcome.

Around here, it's been the time for controversy over online privacy. First there was the big Waldorf Critics dust-up (my post on it, and I'll return to the subject below) and then, starting the night of the 23rd, "the storm in the tweet-cup" (see backstory, below): the..situation blew up between @Doctor_V (Dispatches from the frontline of social media and medicine by Bryan Vartabedian) and  @mommy_doctor (Mild-mannered anesthesiologist by day, suburban ninja mom by night. Tweets are based on fictional characters and situations) .

The latter situation...while I've never met either one in person, I've been following @mommy_doctor for some months.  I've  read some, but all posts on her blog. I find her online company both informative and enjoyable. I have a longer relationship with Dr. Vartabedian: I've been reading, commenting at Dr. Vartabedian's blog, and exchanging correspondence, for over four years.  I continue to have a positive regard for him, and  I'm looking forward to meeting him in person this fall, when he'll be in my neck of the woods for a conference. 

Since this particular event has become so polarized, I want to make my point of view perfectly clear:

Reasonable people can disagree

Now then, on to what I think:

It is my opinion that Dr. Vartabedian was led astray by several assumptions he holds:

1. That any physician not using his or her own name is bound to say "stupid things" and act like "a hooligan" and Unless we know who you are, you don’t count.  If you’re anonymous I have to assume you’re actually a disgruntled medical assistant with an axe to grind.
2. That there's no difference between anonymity (facelessness; lack of identity; having no distinctive character or recognition factor) and pseudonymity (using a name different than the one on your medical license.  Pertains especially in writing and publishing.)
3. That @mommy_doctor published on twitter the actual gender and actual medical condition of a patient.

These assumptions (things that are accepted as true or as certain to happen, without proof) led Dr. Vartabedian to behave badly: he published a blistering post about @mommy_doctor alleged improprieties without without in any way checking reality, including  contacting @mommy_doctor for her point of view. She was held up to criticism and ridicule, both from Dr. Vartabedian and his commentariat:

Disappointed (ironically, an anonymous commenter) Do these people have morals, or even a soul, or even common sense?

DrV No. Probably not. Apparently not.

One of the commenters asked (correctly, in my opinion):

Jennifer Adaeze Anyaegbunam ....Have you reached out to these people and let them know the error in their ways? I think if I made a mistake, I’d rather be alerted privately than (further) exposed in a public forum.

Doctor Vartabedian replied:

DrV Regarding outreach, I don’t engage anonymous people.

Two points:

One: just a few hours before, Dr. Vartabedian had responded to an anonymous commenter -- anonymous in the sense of using a pseudonym that did not link back to any other body of work.

Two: @mommy_doctor, although she doesn't use her real name,  is hardly anonymous.  She has a huge body of work -- over 9,000 tweets.  At the time Dr. Vartabedian wrote his post,  her twitter profile linked to her blog, with entries going several years.

In short, it is my opinion that Dr. Vartabedian allowed his assumptions to guide him to treat a fellow physician without the respect the physician deserved.

I also think that all of us should pay attention to the difference between anonymity and pseudonimity.  It isn't a trivial or hair-splitting distinction.

Part of an email I sent Dr. Vartabedian:

Some of the bloggers I most respect are pseudonymous.   Here are a few:

Example #1 Prometheus at http://photoninthedarkness.com/  Prometheus doesn't use twitter, but does comment widely at blog posts having to do with autism, pseudoscience, and the discredited vaccine-autism connections.

Example #2  Sullivan, part of the group blog LeftBrain/RightBrain. http://leftbrainrightbrain.co.uk/  Sullivan recently (with his wife's consent) agreed to out himself as Matthew Carey PhD.

Example #3 would be Orac Knows, who was pseudonymous for years at Respectful Insolence.  He was outed by others, but when he joined Science-Based Medicine decided to blog there under his own name, David H. Gorski MD

People have various reasons -- personal, professional, or both -- for using pseudonyms, and others equally complicated for setting aside the pseudonym.

Dr. Vartabedian's blog, 33 Charts, is pretty narrowly focused on social media and medicine. Its previous incarnation, Parenting Solved, was again pretty narrowly focused. That isn't to say that all blogs by medical professionals should be that focused, and that indeed might be a motivation for a medical professional to sue a pseudonym.

What if:

• you are a young resident, and want to write about, not patients, but the process of becoming a fully-trained physician in your chosen specialty, and particularly your doubts and worries,  the impact it has on you personally and your family? 
• you are a medical professional who is homosexual, but aren't really out to your professional colleagues?  You write about the conflicts that come up, and your thoughts about coming out.
• you have a child with autism, and want to bring your professional medical insights into autism issues, but don't want to violate your child's right to privacy? 

Those are all actual examples from blogs I have followed over the years.  No, I'm not going to link to them, because some have been taken down, and some sort of let slip over the years that the authors were health professionals.

I think mommy_doctor made an important point here:

 

The Privacy Issue and Demanding the Deletion of Others' Copyrighted Works

One: Health care professionals are bound by Health Insurance Portability Assurance Act (HIPAA), which has privacy restrictions.  Did @mommy_doctor violate a patient's privacy? I don't think so:

Two: This goes back more to the Waldorf Critics example than "storm in a tweet-cup". In W-C instance, an pseudonymous parent revealed that her children had had stress-related behaviors (she identified the behaviors specifically).  She was quite vexed when she, by her carelessness, blew her pseudnonym, and her real name was not listed on a forum, but linked to.  She was so vexed she filed a legal action against another blogger.  She also requested, under the guise of copyright, that all posts relevant to her work be removed, which they were.  Which, incidentally, violated the copyrights of other posters, as their material responding to hers was also deleted.

What do these two episodes have in common?

To me:

• Failure to communicate.  Dr. Vartabedian didn't communicate with mommy_doctor before his post; JennSW didn't start with a simple request to Alicia H. before filing legal action.
• Letting your assumptions push you into jumping to conclusions.

These aren't social media issues, these aren't health care professionalism issues, it's the common struggle to be human and communicate both accurately and honestly.

###

"Storm in a Twitter-Cup" Backstory:

The setting: Mommy_doctor was on call, and had a patient with something wrong for a long time (more than 24 hours) in the genital area--the wrongness may have had something to do with sexual practices, or maybe not.  In the first two tweets,  mommy_doctor expressed concern for her patient.  In the second two tweets,  slight flirtation happened between a random @mommy_doctor follower & @mommy_doctor, then in the last two tweets, mommy_doctor sent two more tweets sympathetic for the patient.

Dr Vartabedian on Physicians' Anonymity:

•  September 22 2010 Bryan Vartabedian at 33 Charts Doctors Should Not Socially  Anonymous

Selected Storm in a Tweet-Cup Responses and commentary

• May 23 2011 Bryan Vartabedian at 33 Charts Unprofessional Physician Behavior on Twitter
• May 24 2011 Shadowfax, MD at Moving Meat: I Don't Buy Your Definition of Unprofessional
• May 24 2011 Pranab at Scepticemia @Doctor_V vs @Mommy_Doctor: Storm in a #Tweetcup
• May 25 2011 Wendy Sue Swanson at SeattleMammaDoc I'm a Physician on Twitter
• May 25 Margaret Polaneczky MD at The Blog That Ate Manhattan Twitter, Doctors, and Professionalism
• May 25 2011 Shadowfax MD at Moving Meat My Guidelines for Blogging
• KevinMD Doctors on Twitter
• May 25 2011 The Angry Pharmacist at The Angry Pharmacist Extreme Unprofessional Makeover or Pimp My Unprofessionalism
• May 26 2011 I Want to be a Pharmacist at I Want to Be a Pharmacist Realistic Professionalism in Health Care Practice
• May 28 2011 Amy Sparkle at All That Sparkles Can't We All Just Get Along?
• Update May 30 2011 Jin Packard at Fresh White Coat: Does Anonymity Help Online Discussions?

Backstory: Waldorf Critics

• May 22 2011 Liz Ditz at I Speak of Dreams Waldorf School Supporter in US Uses Copyright Bullying to Silence Swedish Waldorf Critic

Selected Waldorf Critics Responses and Commentary

• May 18 2011 Alicia H at Zooey discussion; boring mindless stupid on repeat (forever)
• May 20 2011 Alicia H at Zooey Impact
• May 20 2011 Alicia H at Zooey Waldorf bliss-ninny -- not quite so blissful, after all
• May 21 2011 Alicia H at Zooey Some things are difficult to hide
• May 23 2011 Alicia H at Zooey Updates
• Alicia H at Zoey

Comments

[Zzzooey]

'These aren't social media issues, these aren't health care professionalism issues, it's the common struggle to be human and communicate both accurately and honestly.'

Very true. These things happen in real life too, the technology only constitutes a minor difference in how these things happen and unfold as compared to real life. Humans still behave like humans, on twitter, mailing lists, blogs and elsewhere... Of course, the internet would be unbelievable boring if people weren't behaving like humans -- there would be no conversations at all, for one thing (obviously) -- but this also means any conversation is fraught with the same potential for disaster as any other human encounter IRL. I'm guilty of lots of mishaps in this department...

/alicia

[Bryan Vartabedian]

Liz,

While I have tried not to get wrapped up in every post and comment, I wanted to give you feedback. You were one of the first blogs I began reading in 2005-2006. And despite our long history as partners-in-crime in stamping out the anti-vax movement, I have to disagree. There's lots to say. Just a few points:

While this discussion has evolved to center on the rights of doctors to express themselves, it should remain centered squarely on the interests of patients. When it comes to the physicians in the social space, our needs, rights and interests should always be secondary to the interests of the patients we're called to serve.

To serve that end, one question will always serve us well. That question is, 'If this were your brother or father, how would you feel reading these comments?' Or better, if you were the patient under this doctor's care, how would you feel that such things were being said? It's a powerful check on what we feel is a right to free expression.

The HIPAA issue has been raised a number of times but I would agree with you and a number of others who have weighed in, it's hard to see this as a HIPAA violation without knowing all the details of the patient's case. I never suggested that HIPAA was an issue here. It may be, but few of us have the expertise to make that assessment.

If you assume for a moment that this case was effectively fictionalized, the second question that might be asked is, 'How will my patient's see me after reading this?' or better, 'How will my hospital, my colleagues and my community see me after reading these tweets?' These are important questions that doctors should ask themselves before publishing. This discussion should be just as centered on the respect and vision of our profession as it is with the 'rights' of any one physician.

And you're not the first to suggest that I should have approached this person privately. But I don't consider myself professionally accountable to someone who considers herself entirely unaccountable to the medical community or the patients she serves. Anonymous bloggers appear to live by a different standard than the rest of us. I stand behind my words and are consequently accountable for them.

[Liz]

I thought this tweet-stream from @burbdoc was relevant: (they are individual tweets, so read in the conventional way from the top down, not bottom up)

You can read more from @burbdoc by following his tweets: @burbdoc.

[Liz Ditz]

From Shoq

Background on Shoq and his damned "anonymity.

It should come as no surprise to my Twitter stream that I prefer to tweet anonymously. I have several reasons for choosing to do that. The two most important of them are these:

1. First and foremost is the security of my aging mother who, thanks to my political nature, has been relentlessly harassed in the past. But it's also for the sake of my brothers, sisters, nieces, nephews, partners, friends, and acquaintances who have a constitutional right to privacy, or at least a moral right to not be annoyed or harassed because some guy with a cat avatar likes to piss on Republicans, conservatives, pretentious phonies, or plain old crappy bloggers in cyberspace.
2. Secondly, way back in the AOL days, CEO Steve Case took a lot of grief of allowing "screen names" and allowing identities to be anonymous. He defended his decision because he believed that without anonymity, people would not be free to speak their mind politically for fear of reprisals from employers, churches, friends, etc. And as digital information sharing in the medical and insurance community was only recently becoming common, he also felt that any such medical issues should be openly discussable without fear of insurance companies, familes, or employers learning of it.

In my view, Steve Case was exactly right on both counts.To this day, I have many close friends who say they wish that they had kept at least one online persona anonymous so they were free to speak politically, or personally, without fear of their words showing up at the office the next morning—or in the NY Times.

I could spend 10,000 words on this topic, or you could Google for literally millions of discussions on it.

Shoq is a political blogger, not a health care professional (or maybe he is, who knows?) but I think his points are pertinent here.

[Liz Ditz]

Thoughts from a physician who was hounded for his views supporting vaccination and opposing quackery in medicine:

David Gorski at Science-Based Medicine: The Price of opposing medical pseudoscience.

[Liz Ditz]

From my in-real-life pal Karoli (who I knew back when she was pseudonymous). This isn't about health care, it's politics. (emphasis added)

But you know, I’m just sick of it all. Truly sick of it. There’s bunch of lunatics and liars out there, full of hubris and venom. And those are just the ones taking aim at my friends.

This is why I used to write under a pseudonym and probably should have continued to. There are always awful people like Lee Stranahan and Jim Hoft ready to shit on women in order to fulfill their petty little fantasies and collect the paycheck from Big Dick Breitbart. They’re not the only ones, but they’re the ones I’m naming today. I’ll save the ones who bully me while claiming to be big first amendment lovers for another day.

[Bobby Ghaheri, MD (@DrGhaheri)]

edited to add paragraph breaks for readability

I feel compelled to respond to Bryan's comments above.

1) Your argument seems to come from one of patient advocacy. The problem is that your brash approach to @mommy_doctor has done other people harm. Real life patients valued her twitter stream and her blog.

Unfortunately, as you admit, you don't follow anonymous posters. I'm not exactly sure where your moral high ground comes from in deciding that, but regardless, you have subsequently trumpeted the importance that you weren't alone in your criticism. You were "alerted" to this series of tweets by several (still anonymous) people. Why not name them to have a full dialogue? You don't have any journalistic or HIPAA limitations in naming them. That's a double standard.

2) You say "What if this patient were your brother or father?" My response is simple: What if this patient actually existed? If you had done your homework (which you didn't), you would have known that she posts and blogs hypothetically. You would have understood and learned her to be a caring and compassionate doctor. Most importantly, you would have learned that the offending tweets were NOT a pattern of unprofessionalism. If you were truly diligent, you would have named every single anonymous/unprofessional account out there, specifically @burbdoc. But you didn't. Which raises the question about whether you did this because @mommy_doctor is a woman or whether you did this because the subject was phallic in nature.

3) You talk about the events as a "powerful check on what we feel is a right to free expression". I'm confused. Are you implying that you're trying to act as a check on those that YOU deem to be unprofessional? Do the thousands of people that follow her continue to follow her out of obligation? No. They CHOOSE to follow her. This cannot be equated with an unprofessional comment in the elevator of a hospital.

4) You then ask "How will my patients/colleagues view me after publishing this?" Funny, I was thinking about that, but in the context of YOUR reputation. Would I go to a doctor who attacks a colleague in public? Nope. Your initial blogpost tarnishes your reputation, whether or not you believe it. You should care, since you put emphasis on collegiality.

5) But the most curious comment you make is at the end: "I don't consider myself professionally accountable to someone who considers herself entirely unaccountable to the medical community or the patients she serves." This is an argument that my 6 year old makes. It is equivalent to "I don't have to share my toys with Johnny, since Johnny doesn't share his toys with anyone else." This implies that you are ONLY to be held professionally accountable to those who are professional. Conditional professionalism is NOT professionalism. Do you treat unprofessional patients in a different way than your professional patients? If you were truly concerned with professionalism, you would have respectfully:

a) done your homework about her
b) done your homework about other anon Tweeters
c) privately communicated with them
d) criticized her for whatever your objections were in the context that she is STILL your colleague, anonymous or not.
e) been transparent.

Whether or not you agree, I will point out what MANY people feel about your blogpost. They feel that your source(s) of complaint, along with you, are overly conservative and attacked her with a separate agenda. You hurt the patients on Twitter who benefitted from their interactions with @mommy_doctor and you hurt your image of professionalism by how you carried this out.

[Karoli]

As one who in better days was paid to manage health professionals who blogged for a large health website and who has been on the internet for a very long time, I see a very big difference between a person who is a health professional and a blogger/tweeter and a person who is a health professional online to dispense information to readers. As I see it, @mommy_doctor fell into the former category. Many professionals use social media anonymously in order to protect their patients and their families. It's not unheard of and certainly not unethical.

Speaking as a mom and as a blogger who heavily utilizes Twitter, I regret shedding my pseudonym. It constrains me from speaking freely, not because I am afraid of what it will do to *me*, but what it will do to my colleagues and family, who do not share my political viewpoints. Particularly family. As I sit here today, I can tell you that they have not gone unscathed. There are people online who have researched their names, their friends' names, my unrelated business and clients to that business. They have published my home address, my business address, my home phone number, and encouraged harassment. This is all very real and unfair to those unfortunate enough to be related to me.

Should I give up my voice because there are bullies out there? Is my information more reliable because I use my first name? (And yes, that really is my first name. I protect my last name though it's pretty easy to find when you search on my first name).

Anonymity doesn't shield the person. It shields others that person cares about. The minute you say anything on the internet, you own it, regardless of what name one uses. So frankly, I find it rather disturbing that someone's voice has been silenced because they chose to protect their family. Very disturbing, actually.

[Anony Mouse, MS3]

Where is the like button on here? (kidding, kidding ;)

But man, @DrGhaheri, you said everything I wanted to say. And more. Thank you for articulating it so beautifully.

*goes back to studying for peds shelf ;)*