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CLINICAL SYNTHESIS   |    
Communication Commentary: Communicating With the Internet Generation: Challenges and Opportunities
Dorothy Stubbe, M.D.
FOCUS 2012;10:323-326. doi:10.1176/appi.focus.10.3.323
View Author and Article Information

Author Information and CME Disclosure

Dorothy Stubbe, M.D., Associate Professor and Program Director, Yale University School of Medicine Child Study Center, New Haven, CT.

Dr. Stubbe reports no competing interests.

Address correspondence to Dorothy Stubbe, M.D., Associate Professor and Program Director, Yale University School of Medicine Child Study Center, New Haven, CT.

People have really gotten comfortable not only sharing more information and different kinds, but more openly and with more people - and that social norm is just something that has evolved over time.

Mark Zuckerberg

Caring for children and adolescents requires active attunement to developmentally-appropriate and culturally-attuned methods of communication. With many in the younger generation, communication may be most prolific via social media sites, blogs, texting, and other electronic means. Youth who have found a special rapport with their psychiatrist, may naturally want to communicate this trust by “friending” on Facebook. A text message to say that they are running late to an appointment, an e-mail question about a possible medication side-effect, an e-mail attachment with information gleaned from an Internet search about a symptom they have experienced–all are methods of comfortable communication for many younger (and sometimes older) patients. Yet, psychiatrists and other medical professionals disagree about the relative benefits versus hazards of e-communication with patients.

The push for e-communication with patients comes from many sources—patients and policy-makers. In a recent Harris Interactive/Wall Street Journal poll, 75% of respondents said they should be able to schedule medical appointments via e-mail or the Internet, and to e-mail their doctors as part of their overall medical care. The same article cited that the number of physicians who communicate with patients electronically is on the rise—going from 19% in 2003 to 31% in 2007, according to a Manhattan Research survey of more than 1,300 doctors (1).

The Institute of Medicine (IOM) encourages flexible consulting as a key strategy for improving the quality of health care citing that, “Patients should receive care whenever they need it and in many forms, not just face-to-face visits.” This rule implies that the health care system should be responsive at all times (24 hours a day, every day) and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits (2, pg 62). Substituting other forms of care, such as electronic communication, for some face-to-face visits presents an opportunity not only to improve care—make it safer, more effective, patient-centered, and timely—but also to make it more efficient (2, pg. 67). Communications provided electronically are legible, provide for consultation with colleagues around electronically-described symptoms from the patient, and can be added to the medical record quickly and without adding time and interpretation to the information. Many patients who are unable to drive or for whom face-to-face appointments are an undue burden may benefit from communication in an electronic format (3). The basic tenants of the IOM recommendations were reiterated in a later IOM report specific to mental health and substance abuse disorders. It was acknowledged, however, that there may be special challenges posed for mental health providers in using electronic means to communicate with patients (4).

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Clinical vignette

Dr. Smith, a child and adolescent psychiatrist, returns from a long weekend away and checks his e-mail to find an urgent message from Jessica, 16-year-old patient, reporting that her depression has gotten worse and she feels actively suicidal. The message noted that she did not tell her mother, because, “My mom thinks I only say this to get attention. I guess she needs to learn the hard way!” Dr. Smith thought he had provided very good coverage for his absence: he had signed out his beeper to another psychiatrist, he had changed his voice mail to alert patients he was away and to give the covering psychiatrist contact information.

Dr. Smith had communicated by e-mail with Jessica a number of times, but had always told her that e-mail was not the best way to reach him in an urgent situation. Dr. Smith was quite upset when he learned Jessica had taken a potentially fatal overdose of medication and was hospitalized. In talking to a colleague the next afternoon, he continued to review the scenario in his head. “What should I have done differently?” he queried. “I will never allow patients to use e-mail to contact me again,” he concluded.

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Potential hazards of e-communication

As the vignette illustrates, e-communication with patients may be wrought with hazards. “Email does not easily provide the subtle emotive cues often gleaned from vocal intonation and physical demeanour that aid interpretation.”(3, pg. 436). Psychiatry relies on the art of assessment using these measures, as well as others, to accurately assess body language, affect, interpersonal engagement and mental status, which are essential to the determining risk. Busy clinicians often do not access e-mail regularly, getting to urgent or emergent messages many hours later. E-mail between physicians and patients cannot typically be secured, and there is an ever present threat to patient privacy, including unauthorized interception of unencrypted emails, receipt or retrieval of emails by unauthorized people, etc. Clinicians may quickly become overwhelmed by the volume and length of emails (3).

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Social media

The Internet and tools such as social networking sites provide a medium for communication that is faster, farther reaching, and more enduring than other media. Additionally, there is evidence that the Internet fosters disinhibition and feelings of anonymity, which can promote inappropriate disclosure and even behavior in which an individual would not engage offline. Actions taken online may negatively impact a physician’s reputation among their colleagues and their patients, and may also adversely affect the public’s view of physicians (5).

On the other hand, Facebook and other social media sites are here to stay. In a recent study of medical students, over 80% endorsed being members of at least one social network. Only about one-third of medical students use privacy settings, and the percent is likely even less for the older and not-so-tech-savvy users. In addition, 60% of medical schools reported incidents of students posting unprofessional content online (6).

Social networks, blogs, and other forms of communication online have created new challenges to the patient-physician relationship. The Report of the American Medical Association (AMA) Council on Ethical and Judicial Affairs on professionalism in the use of social media, states that physicians must ensure patient privacy and confidentiality in all venues, and maintain professional boundaries and professional demeanor in all Internet activity. Additionally, physicians have a responsibility to bring the potentially unprofessional Internet content of a colleague to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities. Lastly, “physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession” (7, p. 172).

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Blogs, podcasts and Internet sources for public education

The Internet provides a wealth of information to the public. Physicians use the Internet to gather information for evidence-based practice. Consumers use information gleaned from the Internet to be more informed about products, including health-related services. Overall, a better educated public is thought to lead to better health outcomes via timelier accessing of services, informing a healthier lifestyle, and providing patients with information to guide their health-maintenance and treatment decisions. However, the Internet is also rife with false or misleading information, which sometimes spreads quickly and negatively impacts health outcomes. Furthermore, some anxious patients may “catch” every illness they learn about, leading to unnecessary healthcare costs via medical workups (8).

Physicians posting on the Internet must be aware of the accuracy of information provided, and of the health-promoting, as well any potential adverse outcomes, of each post.

There are six general principles psychiatrists should follow (7-12) :

  • Use the most appropriate means of communication for a given task

    • –Use the Internet safely and effectively, ensuring HIPAA compliance and patient confidentiality

    • –Maintain appropriate privacy settings to separate professional and private use of the Internet

    • –Understand that all postings may endure in cyberspace, and avoid postings that have the potential to be damaging

  • Set clear guidelines with patients at the start of treatment about e-communication

    • –Obtain signed waivers for the use of e-mail with patients

    • –Clearly specify when a patient may use e-mail (many psychiatrists only use e-mail for setting up appointments or prescription renewal requests)

    • –Consider adding a sentence to your e-signature about not using e-mail for clinical emergencies and how to contact

    • –Set your e-mail with emergency contact information when you are away

    • –Avoid giving advice over the Internet about matters that require a more thorough assessment

    • –Have a plan of how to deal with texts and e-mails from patients, even if you have told them other ways to communicate

  • Know the Internet policies of your institution and follow them

  • Think about possible repercussions before you “send”

    • –Don’t e-mail impulsively

    • –Beware of subtleties of e-communication and how the message may be interpreted

  • Think about motivations before you Google

    • –Googling your patients without their knowledge is generally considered inappropriate, unless a safety issue is involved

  • Protect your identity

    • –Search yourself intermittently

    • –Take action if there is inaccurate, embarrassing, or libelous information on the Internet about you.

The Internet has provided the public with a wealth of knowledge and an efficiency of communication that is unprecedented. Patients using the Internet may be better informed and may feel less stigma regarding mental health issues, thus seeking treatment earlier and feeling more prepared to participate as active agents in their treatment. Electronic communication is the norm with most younger individuals, and comfort with, and expectations for, e-communication are increasing. The Institute of Medicine has advocated for the use of electronic medical records and electronic physician-patient communication as promoting cost-effective, quality medical care. However, there are many potential drawbacks to e-communication, including the potential for: lack of clarity around physician-patient boundaries; a high volume of electronic communication to which the physician cannot respond in a timely manner; the interception of electronic communications, with subsequent HIPAA violations and privacy concerns; blurring of boundaries between a physician’s private and professional life; the permanence of electronic postings that may have damaging effects for the physician, patient, or the profession. Working with children and youth poses particular challenges, as e-communication has become the norm and expectation for many younger patients. Each physician should clearly communicate their policy regarding the use of Internet communication with their patients, and have a plan for managing urgent or emergent e-communication, in addition to this policy. Successful communication by e-mail depends on a clear and shared understanding by patient and healthcare professionals of its role, advantages, and limitations (1, 7, 8, 9, 12).

Reese  S:  Why you should e-mail your patients.  Mod Med 2008; (April):18
 
Institute of Medicine:  Crossing the Quality Chasm: A New Health System for the 21st Century .  Washington,  DC, National Academy Press, 2001
 
Car  J;  Sheikh  A:  Email consultations in health care: 1—scope and effectiveness.  BMJ 2004; 329:435–438
[PubMed]
[CrossRef]
 
Institute of Medicine: Quality Chasm Series: Improving the Quality of Health Care for Mental and Substance-use Conditions. Washington, DC, National Academy Press, 2006. Free download at http://www.nap.edu/catalog/11470.html
 
Suler  J:  The online disinhibition effect.  Cyberpsychol Behav 2004; 7:321–326
[PubMed]
[CrossRef]
 
Chretien  KC;  Greysen  SR;  Chretien  J-P;  Kind  T:  Online posting of unprofessional content by medical students.  JAMA 2009; 302:1309–1315
[PubMed]
[CrossRef]
 
Shore  R;  Halsey  J;  Shah  K;  Crigger  B-J;  Douglas  SP;  AMA Council on Ethical and Judicial Affairs (CEJA):  Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media.  J Clin Ethics 2011; 22:165–172
[PubMed]
 
Farnan  JM;  Paro  JA;  Higa  JT;  Reddy  ST;  Humphrey  HJ;  Arora  VM:  Commentary: The relationship status of digital media and professionalism: it’s complicated.  Acad Med 2009; 84:1479–1481
[PubMed]
[CrossRef]
 
Snyder  L:  Online professionalism: social media, social contracts, trust, and medicine.  J Clin Ethics 2011; 22:173–175
[PubMed]
 
Farnan  JM;  Arora  VM:  Blurring boundaries and online opportunities.  J Clin Ethics 2011; 22:183–186
[PubMed]
 
Clinton  BK;  Silverman  BC;  Brendel  DH:  Patient-targeted googling: the ethics of searching online for patient information.  Harv Rev Psychiatry 2010; 18:103–112
[PubMed]
[CrossRef]
 
American Association of Directors of Psychiatry Residency Training: Professionalism and the internet. AADPRT website http://www.aadprt.org/pages.aspx?PageName=Professionalism_and_the_Internet_Task_Force, accessed 5/15/2012
 
References Container
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References

Reese  S:  Why you should e-mail your patients.  Mod Med 2008; (April):18
 
Institute of Medicine:  Crossing the Quality Chasm: A New Health System for the 21st Century .  Washington,  DC, National Academy Press, 2001
 
Car  J;  Sheikh  A:  Email consultations in health care: 1—scope and effectiveness.  BMJ 2004; 329:435–438
[PubMed]
[CrossRef]
 
Institute of Medicine: Quality Chasm Series: Improving the Quality of Health Care for Mental and Substance-use Conditions. Washington, DC, National Academy Press, 2006. Free download at http://www.nap.edu/catalog/11470.html
 
Suler  J:  The online disinhibition effect.  Cyberpsychol Behav 2004; 7:321–326
[PubMed]
[CrossRef]
 
Chretien  KC;  Greysen  SR;  Chretien  J-P;  Kind  T:  Online posting of unprofessional content by medical students.  JAMA 2009; 302:1309–1315
[PubMed]
[CrossRef]
 
Shore  R;  Halsey  J;  Shah  K;  Crigger  B-J;  Douglas  SP;  AMA Council on Ethical and Judicial Affairs (CEJA):  Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media.  J Clin Ethics 2011; 22:165–172
[PubMed]
 
Farnan  JM;  Paro  JA;  Higa  JT;  Reddy  ST;  Humphrey  HJ;  Arora  VM:  Commentary: The relationship status of digital media and professionalism: it’s complicated.  Acad Med 2009; 84:1479–1481
[PubMed]
[CrossRef]
 
Snyder  L:  Online professionalism: social media, social contracts, trust, and medicine.  J Clin Ethics 2011; 22:173–175
[PubMed]
 
Farnan  JM;  Arora  VM:  Blurring boundaries and online opportunities.  J Clin Ethics 2011; 22:183–186
[PubMed]
 
Clinton  BK;  Silverman  BC;  Brendel  DH:  Patient-targeted googling: the ethics of searching online for patient information.  Harv Rev Psychiatry 2010; 18:103–112
[PubMed]
[CrossRef]
 
American Association of Directors of Psychiatry Residency Training: Professionalism and the internet. AADPRT website http://www.aadprt.org/pages.aspx?PageName=Professionalism_and_the_Internet_Task_Force, accessed 5/15/2012
 
References Container
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