Can Bloggers Shape Health Care Policy?

M.D. Leaves Profession to Blog

Last week one of the most emailed stories on the New York Times website was about a medical doctor who traded in his profession for a more lucrative one: blogging. No, Arnold Kim M.D. does not blog about kidney diagnosis, his specialty, but rather, rumors about future Apple products. His blog, MacRumors.com is listed as the second most valuable blog ($85 million) on the internet right behind Gawker Media and ahead of The Huffington Post, according to 24/7 Wall St., a financial news blog.

But what if Arnold Kim M.D. did decide to blog about medical tablets rather than speculation of an Apple tablet? What rules and ethics would govern Kim’s blogging? Should he offer medical advice on his blog? Is it ethical to describe the conditions of actual patients? Would it be better that he blog anonymously or that he use his real name? Should he be forthright about the problems facing his profession and the hospital where he works?

Those same difficult questions were asked by Tara Lagu, Elinore Kaufman, David Asch, and Katrina Armstrong in “Content of Weblogs Written by Health Professionals,” an academic paper funded by The Robert Wood Johnson Foundation and published in the Journal of General Internal Medicine last week. The cost of the article if published from JGIM is $32, however, the entire article has been made available on the web by Pharmalot. The objective of the study, in its own words, is to “examine the scope and content of medical blogs and approximate how often blog authors commented about patients, violated patient privacy, or displayed a lack of professionalism.”

The authors of the study take for granted that the influence of medical blogs will continue to grow:

Medical blogs are now part of the literature and media of medicine. These
media include professional and scientific publication and presentation, medical stories and medical dramatizations in books, movies, theater, radio, and on television. Although medical blogs are a new addition to this list, the rapid increase in the use of the Internet suggests that their importance will
grow.

But they are also cautious about the unique unmediated nature of the medium:

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.

The Flea Malpractice Controversy

Without explicitly saying so, the study was seemingly inspired by the controversial case of ‘Flea’, a pseudonymous blogging doctor who revealed the details of a patient’s death after a malpractice case was brought against him. Incredibly, ‘Flea’, now publicly known as Robert P. Lindeman, blogged his way to a costly out-of-court settlement after publishing posts which ridiculed the plaintiff’s case and the lawyer, and accused members of the jury of dozing. It was, according to the Boston Globe’s Jonathan Saltzman, “a Perry Mason moment updated for the Internet age.”

Lindeman’s blogging as a court defendant, much like his blogging as a pediatrician, offered insight into malpractice cases which is not widely known among the general public. According to the Boston Globe article:

In April, before the trial began, [Lindeman] wrote about meeting with an expert on juries who advised him how to act when he was cross- examined. Flea was instructed to angle his chair slightly toward the jury, keep his hands folded in his lap, and face the jury when answering questions, slowly. “Answers should be kept to no more than three sentences,” he wrote.

The consultant told him juries in medical malpractice cases base verdicts almost entirely on their view of a doctor’s character.

“We’ve said it before, and we’ll say it again: If the basis of this case is that Flea is an arrogant, uncaring jerk who maliciously neglected a patient, resulting in his death, the plaintiff will not win, period,” Flea wrote.

Held to Higher Standards

In total, the authors of Content of Weblogs Written by Health Professionals identified 271 medical blogs with the help of Google and three medical blog aggregators: Medlogs, Yahoo Health and Medicine Blogs and The Medical Blog Network. In each of the 271 blogs, they examined five posts from throughout 2006, but do not explain how those five posts were selected. (I certainly wouldn’t want my own blog portrayed in an academic study based on just five blog posts.)

They found that over half of the bloggers provided sufficient information to reveal their identities. Individual patients were described in over 40% of the studied blogs and were portrayed positively in 16% of blogs and negatively in nearly 18%. “Of blogs that described interactions with individual patients, 45 (16.6%) included sufficient information for patients to identify their doctors or themselves. Three blogs showed recognizable photographic images of patients. Healthcare products were promoted, either by images or descriptions, in 31 (11.4%) blogs.”

The authors of the study don’t judge the torrent of new medical blogs to be either good or bad. Rather, they acknowledge that blogs “allow physicians and nurses to share their narratives, knowledge and
experience with the healthcare world” and “accurately portray the challenges facing our professions.” However, they caution that “health professionals who share private thoughts in public settings risk revealing confidential patient information or otherwise reflecting poorly on the profession” and recommend that healthcare professionals who blog hold themselves to higher standards.

The author of Clinical Cases and Images, responding to the study, offers tips for fellow medical bloggers such as “write as if your boss and patients are reading every day”, “comply with HIPAA“, “use a disclaimer”, and “get your blog accredited by the Heath on the Net Foundation.” Kevin, M.D., one of the most popular physician bloggers, also responded to the study, agreeing that “physician blogs that write about patients do need to be held to a higher than normal blog standard”, but that physician blogs should not be required to disclose conflicts of interest nor be held to the same standard as medical journals. Ed Silverman, who blogs at Pharmalot, is bemused that doctors so frequently complain about not having enough time to see patients, but do manage to find time to blog about them. Dr. R.W. Donnell, who blogs at Trusted.MD, notes that there is still little consensus on whether medical bloggers should publish anonymously or not.

Can Health Bloggers Shape Health Policy?

The study also notes that medical blogs “can accurately portray the challenges facing our professions.” But can they be harnessed to help find solutions to those challenges and to shape local, national, and even global health care policy?

This is the central question of a panel discussion on Tuesday, July 29 sponsored by the Kaiser Family Foundation. According to the blurb:

The briefing will highlight how the traditional health policy world has embraced blogging and will feature a keynote address by U.S. Department of Health and Human Services Secretary Michael Leavitt, the first cabinet officer to author an official blog, followed by a moderated discussion with a variety of health policy bloggers and a media analyst.

According to the About Page of Secretary Mike Leavitt’s blog, he is:

taking time to blog as a way to foster public discussion. The blog is the result of the Secretary’s continuing desire to engage Americans in the exchange of ideas on health care and the provision of human services. It provides an opportunity for the Secretary to share his observations as well as a means for him to have an open conversation about health and the related challenges that face the nation. The blog is intended to be a dynamic online conversation and the Secretary welcomes your ideas for overcoming those challenges.

Other health bloggers on the panel include Jacob Goldstein who blogs at the Wall Street Journal’s Health Blog, John McDonough a senior adviser for Senator Edward Kennedy who blogs at Commonhealth and used to blog at A Healthy Blog, Michael Cannon who is the Cato Institute’s director of health policy studies and frequent blogger, as well as Kaiser Family Foundation CEO Drew Altman who has so far published at least one blog post himself.

Global Voices for Global Health?

Other health-focused philanthropic foundations are also looking toward the blogosphere as a place to stimulate debate about health care policy. Last week I was invited by the Rockefeller Foundation to help cover a conference they have organized about Global eHealth. (You can see my conference coverage here.) Rather than sticking to press releases fed to mainstream journalists, the conference organizers realized that bloggers could help reach new audiences and foster more interactive discussions around how technology can be used to improve health care in developing countries.

Similarly, the Health Media initiative of Open Society Institute’s Public Health program has partnered with Rising Voices, the Knight News Challenge grantee which I direct, to train staff at six health-focused NGO’s in the developing world how to use citizen media like blogs, podcasts, and online video to spread awareness about their work and the populations they work with.

We have hired Juhie Bhatia as Global Voices‘ public health editor to help filter and feature the content produced by these six NGO’s as well as content from the greater health blogosphere worldwide. Already she has published a fascinating piece examining Indian bloggers’ reactions to a controversial proposal in Maharashtra to make HIV testing compulsory before a couple is able to marry. Like so many posts on Global Voices, it is available in multiple languages including Bangla, French, Macedonian, and Hindi.

Whether a single blog can help influence health care policy in the United States or, for that matter, in Ukraine or Romania, remains to be seen. But it is undeniable that health-focused blogs have alredy become part of what the authors of the article from the Journal of General Internal Medicine refer to as “the literature and media of medicine.” The ultimate goal, of course, is that more information and more discussion will eventually lead to better healthcare, better health policy, and healthier lives.