As the rage of Internet blogging spreads across professions, doctors' observations and opinions about patients _ some expressed in graphic detail _ are now ending up on the Web for all to see.
Hundreds of doctors across the country are writing Internet diaries that sometimes include harsh judgments of patients, coarse observations and distinct details of some cases.
Critics say the blogs cross into an ethical gray area and threaten patient privacy while posing liability risks for health workers and their employers.
A popular medical blogger, for example, wrote this in discussing an 18-year-old who on Christmas Day had her third baby:
"I don't mind it so much when a young single woman comes in with her first pregnancy, because anyone can make a mistake. But when that woman gets pregnant repeatedly, time after time, she degrades herself and her children, by condemning herself to a lifetime of dependency and irresponsibility."
The writer, who identifies himself as a neonatologist working in a U.S. urban area, writes about his practice at www.neonataldoc.blogspot.com.
The anonymity provided by blogs has proved to be a powerful lure for doctors and other medical professionals, who, sworn to strict rules of confidentiality regarding patients, have few outlets to speak their minds.
Although many bloggers stick to innocuous subjects that don't involve patients, others make patients the focus of their writing. The risks are far-reaching and ultimately could damage the medical profession, critics say.
"One of the fundamental aspects of medicine is that patients have to feel free to tell doctors everything," said Dr. David Stern, who teaches professionalism at the University of Michigan Medical School. "They're not going to tell us everything if they're asking themselves when they come in to see their physician, `Is my doctor going to blog about me?'"
TJ Bucholz, spokesman for the Michigan Department of Community Health, under which the state's medical licensing board operates, said he thought neonataldoc's blog stayed inbounds.
"I don't see a lot of blatant HIPAA violations," Bucholz said, referring to the Health Insurance Portability and Accountability Act of 1996, which established national standards to protect personal health information. "They're using first names ... but from my perspective, if someone were to identify themselves in this blog, he is looking at very serious charges, not the least of which is losing their license."
Medical blogging is so new that medical boards, schools and professionals disagree on what is acceptable.
The doctor who posts on neonataldoc.blogspot.com spoke to the Detroit Free Press on the condition of anonymity, saying the blog was a place for him to say things he does not otherwise get to express.
"I wanted to say what I wanted to say," he said. "I have many thoughts about single moms. I know of no other forum for doing this.
"I mainly wrote it for my own self," he added. "I had no idea it would take off like this or that the comment section would become what it has."
His blog, which includes comments on specific cases in dated entries and periodically mentions information about his hospital such as what food is offered in the cafeteria, can get up to 800 hits a day.
Posts often draw two dozen or more responses from readers.
Some of neonataldoc's posts seem crude. In December, he wrote about defecation during birth and, separately, a 17-year-old who was giving birth in the nude.
"`She doesn't have any clothes on!' I said to (the nurse), and we both started giggling." The doctor went on to describe for Internet readers some characteristics of the woman's breasts: "She had the hugest ... nipples I had ever seen."
Other blogs are equally candid:
"I got called to the ER to deal with a man who had placed a piece of plastic tubing (an aquarium pump tube to be exact) up his urethra, and it was now stuck inside and neither the patient nor the ER physician were able to retrieve it."
(That's from urostream.blogspot.com.)
"I informed a patient's parents that we would call them when their child was off the heart bypass machine and back in the intensive care unit. That went down like a lead balloon as the child was in fact having spinal surgery. Oops."
At scalpelorsword.blogspot.com, the writer generated controversy for a post poking fun at a gay patient: "He wouldn't let me probe the wound, so we had to be satisfied with the tiny amount of pus that was expressed. He tolerated the procedure like, well ... John Edwards, " an apparent reference to conservative commentator Ann Coulter's use of a homophobic slur to refer to Democratic presidential candidate Edwards.
Critics find the trend troubling, not only because of the risk of compromising patient privacy but also because of potential liability for hospitals.
"We're talking about professions that have legal and ethical obligations regarding privacy that are governed by federal statutes," said Terry Bonnette, a labor and employment attorney with the firm Nemeth Burwell. "You should assume when you're blogging that your anonymity is not absolute.
"Employers should be very careful about this. They are the ones who have the most to lose, really. A hospital has every right to protect its image and reputation."
Some blogs give advice on how to comply with HIPAA. The site www.geneticsandhealth.com has an honor roll, led by Dr. Hsien Hsien Lei, listing blogs that do well at abiding by privacy laws and disclosing biases.
"I just felt sites were not up front about their affiliations," Lei said.
"The line is very fuzzy," Lei added, when it comes to maintaining patient privacy. "Every single doctor who blogs kind of defines it for themselves."
The author of bulgingbag.blogspot.com said he stopped blogging because he wasn't sure exactly what constituted breaking the law.
"There are no real guidelines, and I just felt I couldn't talk about the things I wanted to talk about without feeling like I was crossing some line," he said.
(EDITORS: STORY CAN END HERE)
The only acceptable way to blog safely about patients is to ask for their consent, University of Michigan's Stern said.
"Absent that, you're on shaky moral ground," Stern said. "The only way you can totally protect confidentiality is to not say anything."
Marie Doherty, an administrator in charge of nurses at Royal Oak, Mich.-based Beaumont Hospitals, said she was alarmed at the amount of patient information on some doctor blogs.
"There are a lot of patients who don't want any kind of information about them on the Internet, and that's their choice," said Doherty, whose primary role is that of a patient advocate. "Each case has to be dealt with individually. If a patient is concerned with blogging, they should definitely ask their doctor if they have a site."
(EDITORS: STORY CAN END HERE)
Down the hall from Stern's office, Dr. Robert Ruiz, associate director of admissions at the University of Michigan Medical School, said some flexibility is acceptable.
Ruiz supervises medical student blogs.
Students are allowed to write about patients if they obtain permission. If the entry focuses on the student rather than the patient, the student can write without the patient's knowledge.
"We ask that they change nonrelevant factors," Ruiz said. "If the gender isn't an issue, we tell them to change the gender, or we ask them to mix up the stories. They might write today about something they experienced months ago."
That fuzziness doesn't cancel out the good that has come out of medical blogs, said Lei, the genetics blogger.
Blogs disseminate research and opinions quickly and can give patients access to doctors, many times on even ground.
"Patients forget that doctors are people," Lei said. "There's a tendency to think that they're either God or people who just want to shove pills down your throat. When you're reading their blogs, you see that they're real people.
"Also, on these blogs, comments are open," she added. "If you have a concern, you can easily leave a comment. It's a wonderful way for patients to have access to doctors."
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