Generally speaking, news editors rarely accept for publication any letters to the editor that are submitted anonymously. To do so would merely encourage the trolls to spew forth.  Discouraging anonymity is a good thing, I believe, because the jerk-to-normal person ratio out there is already perilously high even without encouragement. For example, the Toronto Star – unless agreeing to specific requests to protect confidentiality for valid reasons –  is just one of many that advise readers:

“Letters to the editor must include the writer’s full name – anonymous letters and letters written under pseudonyms will not be considered. For verification purposes, they must also include the writer’s home address, e-mail address and telephone numbers. Writers should disclose any personal or financial interest in the subject matter of their letters.”

And imagine what would happen if The Star or other media outlets let us just willy-nilly vent publicly under fake names whenever we like.

Oh. Wait a minute. That’s already allowed, and it’s called social media.  

Recently, we’ve seen increasing evidence of what can happen under that potential cloak of anonymity when health care professionals take to the internet to post blogs or tweets or other social media updates under names that are not their own.

The results can reveal what Dr. Henry Potts‘ study in the U.K. described in 2005 as “disinhibition”, as reported in the journal, Health Information On The Internet. His take on this issue is that it’s the nature of online communication, the absence of social cues, and the perceived intimacy/anonymity that combine to make people less inhibited in their online behaviour – and disinhibition, he explains, can be problematic when it leads to “flaming” (deliberately provocative or insulting comments).

Consider Dr. Moderate (identified online only as a GP who enjoys cycling and coffee, somewhere in the U.K.). Shortly after launching his personal yet anonymous blog called The Moderate Doctor, Dr. Moderate was compelled to euthanize an entire section of it called The Rules because of the negative feedback this page was attracting online. As he explained on his freshly retitled page, The Rules Have Gone:

“I can’t stand the grief. Tried to post some ideas for a bit of fun – seems that too many people did not like them. I started with an idea after yet another of those difficult surgeries, and soon developed a set of rules that picked out some of the problems that patients bring to us that can cause frustration within. 

“The Rules were not supposed to be patient-centred – they were doctor-centred and that was their point.”

“Not supposed to be patient-centred”? Trouble is, I guess Dr. Moderate forgot a pretty basic truism of having “a bit of fun” online: it’s public!

What you write is out there for all the world to see, unless you set up a private account open only to members.  Anybody – yes,  including your own patients – can and will read what you write without the slightest regard for what you think your target audience is “supposed to be”.

And venting online – particularly about any group of people as vulnerable as sick patients are – is quite unlike you and a bunch of your frustrated colleagues privately commiserating and debriefing over a few beers after a long frustrating day about all those maddeningly annoying people who represent the reason you went to med school in the first place.

One might indeed wonder how did such smart people forget such a basic fact about the internet? Isn’t that, after all, why we call it the worldwide web?

To me, the only surprising thing about the Dr. Moderate story is that he seemed surprised.

Meanwhile, around the same time as Dr. Moderate’s confusion was just starting, I read a tweet last week by a physician named Dr. K – or @medschooladvice on Twitter . Dr. K has about 46,000 Twitter followers; a quick browse through the list of his followers reveals many are medical students.

This tweet simply read:

I suspect that this was meant in the dark humour/in-joke spirit of high hilarity common to every profession. But as Angela Dunn of Health Is Cool recently observed, a “shock doc” Twitter approach, unfortunately, also coaches other doctors on the use of Twitter:

“Some doctors are letting their belief that they need to be entertaining on Twitter overtake common sense – and a sense of humanity.”

Responses to Dr. K’s inane tweet were swift and, to me, distressing. As a heart attack survivor who’s spent way more time than I would ever want to in hospital, specialists’ offices and pain clinics, I cringed reading these responses. They ranged from “LOL!” to this witticism from another (anonymous) person calling himself ER Doc – or @bigblast – who wrote:

How’d you like this brainiac to be in charge of your care during your next scary trip to the Emergency Department?

And what does this say about the people we patients are trusting to touch our bodies and provide care for us when we need their help? Or worse, about the young med students who will one day fill that important role, who have already grown up with Facebook, updating their every waking moment with nary an unexpressed thought, no matter how mundane or inappropriate or downright stupid?

Speaking of stupid, Stony Brook University Medical Center in Long Island announced not long ago that it was developing a revised ethics policy after one of its medical students posted a photo on Facebook of a classmate posing with a big thumbs up next to a dead body. That’s really hilarious, kids – especially to the family of the deceased. (More on this at Doctors Behaving Badly Online)

Back to Dr. K:  my own Twitter response to his oh-so-cleverness:

Only one doctor out of the thousands who likely read Dr. K’s original tweet on May 5th seemed to oppose his statement publicly. Dr. Matthew Siuba, an internal medicine/pediatrics resident in Michigan, wrote this in response to my reaction:

Notice that Dr. Siuba is not afraid of using either his own name or his photo. Even given his blunt assessment of Dr. K, you know that here’s a guy who has no reason to hide behind a fake identity on social media.

But cowardice isn’t the sole reason physicians might decide on posting anonymously. The use of pseudonyms is already a common feature among many online users such as gamers, or those with legal, military, criminal, workplace or cultural restrictions (in Japan, for example, online pseudonyms are the norm in almost all circumstances).

But not all of these folks are doctors, and playing Second Life is not the same as practicing medicine.

Some physicians may cite independence or conflicts of interest as a factor in less-than-truthful bylines. But even those docs in high-profile positions at major hospitals or universities commonly present their real names online right along with clear disclaimers reminding readers that their opinions are their own and not those representing their organizations.

Whatever objections doctors may have to being truthful about their online identities can be readily countered with examples of physicians who have been happily overcoming those objections all along – including docs like Dr. John Mandrola, Dr. Elaine Schattner, Dr. Jonathan Tomlinson, Dr. Margaret Polaneczky, Dr. Jan Gurley, Dr. Bernard Lown, Dr. Yoni Freedhoff, Dr. Lawrence Cresswell, Dr. Howard Luks, Dr. Mike Evans, Dr. Wendy Sue Swanson, Dr. Jen Gunter and all of the doctors over at Science-Based Medicine – my own list is long and growing, to name just a handful of those docs whose online writing is both compelling and proudly their own.

In fact, I’d say that doctors who boldly publish under their own names enjoy more credibility on social media than those who write anonymously.

The doctors I am concerned about are not those enrolled in a witness protection program. I’m talking about the vast majority of health care professionals already jumping onboard the social media freight train.

With docs being urged to join the universal lockstep march towards embracing social media (whether or not they’ve thought through exactly what they want to communicate with the world), I suspect some – like the übertweeter Dr. K – simply do not ‘get’ emerging professional social media guidelines urging docs to avoid engaging in any online behaviour which could be perceived as unprofessional, inappropriate or offensive by others.

In fact, I’ve noticed that such doctors are often the most openly disdainful of any attempt to advise them on what they should or should not be doing online – or anyplace else.

Dr. K’s actual name, Sujay Kansagra, is nowhere to be seen on his Twitter account; we are easily able to come up with his real identity, however, by tracking the book that he plugs on his site.

And really – why post anonymously when you just can’t resist flogging a book that has your name clearly prominent on the book jacket?  In his real life, Dr. K is a pediatric neurologist at Duke Medical Center in Durham, North Carolina, just in case you or somebody you care about are considering a future consultation.

But why post anything online that you wouldn’t have the guts to say under your own name?

The reality is that those who post anonymously online are far safer should they be gripped with the sudden urge to engage with zero consequences in troll behaviour (like mean-spiritedness, disrespect, abuse, harassment, offensiveness, profanity, lack of perceptible humanity) than they ever likely would be if their own identities were honestly revealed. Easy-peasey when you think nobody knows who you are.

I’m not saying, of course, that all those using pseudonyms online are trolls – just that most gutless trolls work anonymously.

Meanwhile, remember Dr. Moderate?  Here’s what he had to say on the sad day that The Rules page died on his blog:

“If you have come to this site hoping to find The Rules then I am sorry to disappoint you.  I have removed them today from the site as it has become apparent that the public domain is not the place for them to be shared.

“How do we let off steam/share frustrations or discuss with like-minded people?

“The answer would seem to be:  Privately.”

Bingo! Congratulations on your grasp of the bleedin’ obvious, Dr. M.

And while some doctors (who seem to favour deleting the word ‘professional’ from the job title  of ‘health care professional’) may mourn the passing of The Rules, let us remember the wisdom of Dr. Farris Timimi, Medical Director of the Mayo Clinic Center for Social Media. As such, Dr. T  knows a thing or two about what’s appropriate and what’s less-than-appropriate for health care providers to post online.

His brilliant 12-word social media guide for health care professionalism is:

“Don’t Lie, Don’t Pry, Don’t Cheat, Can’t Delete, Don’t Steal, Don’t Reveal”

It seems that Dr. K’s scalpel tweet of May 5th has now been quietly excised from his Twitter feed.  I live in hope that I may have had even the tiniest part in that.

♥ With special thanks to Marie Ennis-O’Connor from Ireland, who initially inspired this post

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See also:

• 10 tips: Social Media Highway Code for doctors
• Dr. Sherry Turkle: “I share, therefore I am”
• “Distracted Doctoring” – updating your Facebook status in the O.R.
• Why some people should avoid social media completely”
• Doctors behaving badly online

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Q:  If you’re a doctor who posts anonymously online, tell us why

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