Facebook Friend Request - A young doctor gets a message from a dying patient

From the NYTimes:

"Last winter, in the middle of my intern year, I became Facebook friends with a young man who was dying in the intensive-care unit. An investment banker in his mid-20s, he thought he was healthy until a fluttering in his chest and swollen ankles took him to a doctor. Now he was in the I.C.U. with a rare cardiac condition and the vague possibility of a transplant.

“Are you on Facebook?” he asked me. “I’ll friend you, and you can see the pictures.”

He’d been sending upbeat status updates from the I.C.U.; to read them, you’d never know he was so sick, but to me they were missives from a dying man."

Comments from Google Buzz:

Mark Hawker - Just before I do comment, I'd like to say that I do not have a clinical background so I cannot comment or empathise on the writer's clinical content or her situation. However, I can comment on my personal feelings about the story.

My reaction to this story was one of shock. A testosterone-filled medical student who got herself into a preventable situation. The lines that made me most uncomfortable were:

- "This boy on Facebook was, well, hot."
- "I didn’t think there was an ethical principle about following a patient on Facebook, and I didn’t worry that he’d see a picture of me in a bikini on my page."

It's not the fact that she didn't reply to this patient's message but the fact that she got herself into that situation in the first place. Would a doctor take a patient's telephone number to "see how they were" or go out bowling with them? Her emotions got the better of her and this led to more stress/turmoil in the future stages of the case. Does she feel this way to all her patients, or just the good-looking ones?

Secondly, "I signed on to our medical-records system and followed the notes that led — inevitably now — to his death." What now? In my opinion she had no right at all to do this. Her access was not about clinical care at all, nothing shy of being nosey. Does she also look up the medical notes of her ex-boyfriends etc.?

i just can't see how this would be OK? Maybe I'm missing the point... 10:51 am

Ves Dimov, M.D. - I see your point and I think it's a valid one. We already know that some physicians have hard time looking at patients only from a professional point of view, and I agree with you that this is a problem. It has little to do with Facebook though since this mind set can be propagated through any communication channel. Facebook provides some misunderstood "privacy", if not anonymity. 11:04 am

Mark Hawker - Yes, that's right. Facebook is merely a "medium" much like telephone, an address, papyrus, etc.

I can't come to imagine how hard it must be to separate from a patient but can you be too human which can lead to enormous emotional stress in the long-term? Maybe this encounter led the writer to feel lonely about her own situation? Would she have reacted the same if she found that he was not single? Though, this is information she should never really have found out about...

Can this type of separation be taught, or is it embedded within us and cannot be taught? 11:11 am

Ves Dimov, M.D. - "Can you be too human?"

Yes. There are two rather simplistic schools of thought for professionals: cold and technical but gets the job done vs. warm and fuzzy, bubbly and compassionate... "When you have appendicitis, you want a surgeon, not a poet holding you hand for comfort."

"Can this type of separation be taught?"

I think so. It's part of the professionalism - one of the 6 core competencies of a physician training:

http://casesblog.blogspot.com/2008/03/remembering-acgme-6-core-competencies. 11:18 am

Anne Marie Cunningham - I think I did read this around the time that it was first posted on NYT... in fact I'm sure I did. At the time I was struck by how this doctor communicated her confusion over many things... not being able to help this patient... realising that he had a life before being a patient... struggling with his death. It didn't strike me that she had been unprofessional. She engaged in small talk with the patient and he invited her to be a friend on Facebook to see the photos of his trip. She could have said "No, I'm not on Facebook" or "No, I don't think it is appropriate to be friends with a patient on Facebook", but she didn't. Instead she allowed him to invite her to see those photos. We don't know how public his profile page was. Perhaps it was public. Maybe she shouldn't have looked again. But she did. With regards to following up his medical story through his notes... well I don't think this is inappropriate either. Looking at what happens to patients after you have looked after then is how you learn. It's what we encourage students to do and it absolutely the best way to learn when you are a doctor too. Should she have written this account? Well, through it... and I presume she has changed enough so that we couldn't figure out who the patient is.... we are given something to think about. We are able to think about what she should have done. We are able to think about what we would do if we are patients. This is a generous act because she is sure to know that some people will be critical. Most of the comments criticise her for not responding to this direct message and it is what she criticises herself for. Should she have gotter herself into this situation? Who knows. Would she do it again? Only she knows. I commented on twitter, that I don't think that her behaviour was unprofessional. That doesn't mean that I think it was professional. I think that she is struggling with a professional identity. That's not surprising because she is a very young doctor.

I'm not sure from reading this if she ever actually did become his friend on Facebook. Responding to a message allows people to see more of your profile, and it sounds as if that is why she made the remarks about the possibility or not of him seeing her in a bikini. Perhaps it wasn't something to worry about because there are no photos of her like that on Facebook. With regards to seeing him as 'hot', I take that she sees that in contrast to his lack of hotness in a hospital bed. She gets to see him as the well person he was before being a patient. It probably made the tragedy of his story, and the sadness of his situation even more real to her.

Should she not have known any of this? Some would say, as a few commenters do, that the sadness is that she only came to know about him as a whole person through Facebook. The nature of medicine is that we mostly only ever get to see our patients on our turf. Seeing and knowing about their whole lives, if they are happy for us to, is not wrong or innapropriate.

Medicine is not just about information. It is about caring and that is what this story tells us about. 7:08 pm

Anne Marie Cunningham - PS For a critique of 'professional distance' as professionalism I suggest this paper by Joanna Shapiro http://www.peh-med.com/content/3/1/10
No one ever said that being a doctor was easy! 7:14 pm

From Twitter:

@markhawker

Read this account... http://nyti.ms/dcM271 Do you think this is funny or very, very worrying? Do people think this article about a medical student and Facebook is funny? http://nyti.ms/bc80tC Maybe I'm getting too old for this...

Anyone care to count the number of ethical breaches that she abused in the story and, worryingly, admitted to. Would that happen in the UK?!

I'm still torn as to how "human" a doctor should be whilst working. Well, maybe one not driven entirely by testosterone. Yes, does require a lot of thought! I was just taken aback by the article & how the world seems to think these things are OK.

Confidentiality, looking up medical records unauthorised, wishing to respond to a "casual online message". Qualities of a Dr? Nothing catches your eye about testosterone-crazed medical students let loose to breach confidentiality regulations and ethics? You don't think that this student maybe got herself in too deep because of a hot-blooded crush which affected her clinical judgment? Would she give him a phone number etc.? Has the ICU been mistaken for a bar?! Is there a difference between being human and emotional?

It's not the fact she didn't communicate, it's the fact she got herself into that position in the 1st place.

"This well-intentioned resident naively violated HIPAA by accessing records for no purpose other than her own personal interest." Thank you.

There are many factors that contribute to this: personal, age, experience etc. I think her "issue" was preventable.

Interested in learning about the psychological effects of these interactions and skeptical about the altruism of the writer.

Interested to hear your thoughts. I think the article is wrong in many ways... Will watch out for your analysis.

I wonder if she removed him as a Facebook friend... If not, I could find his name, right? Not too anonymous.

Note:

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References:
Lives - Friend Request - NYTimes.com.
Image source: Wikipedia.

1 comment:

  1. What if, just the fact, that she cared and remembered his name helped this patient on some kind of emotional level?

    I guess, ultimately, it seems to me that she was able to rise to the task of risking being hurt emotionally, to give a patient, quite possibly, what he really needed. What else could she give him? She couldn't give him his life back, so why not reach out and let him know in even a small way that she heard what he said....recognized him as a person, and didn't breeze away in the usual *time-is-everything to me* medical environment that isn't serving doctors or patients very well.

    How refreshing it is when doctors risk their own well-being in some truly type of altruistic effort. I realize it's not always wise, but sometimes in an effort to heal someone inwardly, it's worth the risk.

    I don't think doctors are just lab coats, but either are patients simply blank faces in a crowd. Medicine doesn't need to be an anonymous endeavor.....it's risky emotionally from whatever side of the bed your view is from.

    Do the rules of professionalism really trump charity?

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