Friday, May 30, 2014

Should Doctors ‘Google’ Their Patients?

Beware of what you share. Employers now routinely utilize internet search engines or social network searches to obtain information about job applicants. A survey of 2,184 hiring managers and human resource professionals conducted by the online employment website revealed that 39% use social networking sites to research job candidates. Of the group who used social networks to evaluate job applicants, 43% found content on a social networking site that caused them to not hire a candidate, whereas only 19% found information that that has caused them to hire a candidate.

The top reasons for rejecting a candidate based on information gleaned from social networking sites were provocative or inappropriate photos/information, including information about the job applicants' history of substance abuse. This should not come as a surprise to job applicants in the US. After all, it is not uncommon for employers to invade the privacy of job applicants by conducting extensive background searches, ranging from the applicant's employment history and credit rating to checking up on any history of lawsuits or run-ins with law enforcement agencies. Some employers also require drug testing of job applicants. The internet and social networking websites merely offer employers an additional array of tools to scrutinize their applicants. But how do we feel about digital sleuthing when it comes to relationship that is very different than the employer-applicant relationship – one which is characterized by profound trust, intimacy and respect, such as the relationship between healthcare providers and their patients?

The Hastings Center Report is a peer-reviewed academic bioethics journal which discusses the ethics of "Googling a Patient" in its most recent issue. It first describes a specific case of a twenty-six year old patient who sees a surgeon and requests a prophylactic mastectomy of both breasts. She says that she does not have breast cancer yet, but that her family is at very high risk for cancer. Her mother, sister, aunts, and a cousin have all had breast cancer; a teenage cousin had ovarian cancer at the age of nineteen; and that her brother was treated for esophageal cancer at the age of fifteen. She also says that she herself has suffered from a form of skin cancer (melanoma) at the age of twenty-five and that she wants to undergo the removal of her breasts without further workup because she wants to avoid developing breast cancer. She says that her prior mammogram had already shown abnormalities and she had been told by another surgeon that she needed the mastectomy.

Such prophylactic mastectomies, i.e. removal of both breasts, are indeed performed if young women are considered to be at very high risk for breast cancer based on their genetic profile and family history. The patient's family history – her mother, sister and aunts being diagnosed with breast cancer – are indicative of a very high risk, but other aspects of the history such as her brother developing esophageal cancer at the age of fifteen are rather unusual. The surgeon confers with the patient's primary care physician prior to performing the mastectomy and is puzzled by the fact that the primary care physician cannot confirm many of the claims made by the patient regarding her prior medical history or her family history. The physicians find no evidence of the patient ever having been diagnosed with a melanoma and they also cannot find documentation of the prior workup. The surgeon then asks a genetic counselor to meet with the patient and help resolve the discrepancies. During the evaluation process, the genetic counselor decides to ‘google' the patient.

The genetic counselor finds two Facebook pages that are linked to the patient. One page appears to be a personal profile of the patient, stating that in addition to battling stage four melanoma (a very advanced stage of skin cancer with very low survival rates), she has recently been diagnosed with breast cancer. She also provides a link to a website soliciting donations to attend a summit for young cancer patients. The other Facebook page shows multiple pictures of the patient with a bald head, suggesting that she is undergoing chemotherapy, which is obviously not true according to what the genetic counselor and the surgeon have observed. Once this information is forwarded to the surgeon, he decides to cancel the planned surgery. It is not clear why the patient was intent on having the mastectomy and what she would gain from it, but the obtained information from the Facebook pages and the previously noted discrepancies are reason enough for the surgeon to rebuff the patient's request for the surgery.

Two groups of biomedical ethics experts then weigh in on the case and the broader question of whether or not health care professionals should ‘google' patients. The first group of ethics experts feels that uninvited patient ‘googling' is generally a bad practice for three main reasons:
  1. It allows healthcare professionals to withdraw from their patients and start relying on online data and information gleaned from social networking sites instead of interacting with the patient and addressing the key issues head-on.
  2. The ‘googling' of patients erodes the trust between the healthcare professional and the patient. Patients might feel a sense of betrayal that the healthcare professional "spied" on them.
  3. An internet search or review or social network pages linked to the patient represents an invasion of the privacy of the patient. The patient should have the right to decide what information to disclose and what not to disclose, but by surreptitiously obtaining this information, the healthcare provide circumvents the right to privacy of the patient.
A separate panel of reviewers arrives at a very different conclusion and specifically points to this case as an example where it was imperative to ‘google' the patient. As this panel points out, the genetic counselor used a legal method to search the internet and found information on public Facebook profiles after having found many red flags and inconsistencies in the patient's medical history. By finding the information on Facebook, the surgeon and the counselor were able to prevent a self-injurious, deceptive and possibly fraudulent scheme of the patient to go forward. This panel of experts goes as far as saying that it would have actually been irresponsible to not perform the Google search after all the red flags and inconsistencies were identified.
As with all ethical dilemmas, it is difficult to find the correct answer. The first panel brings up good points that the relationship between a healthcare professional and a patient is characterized by trust and respect of privacy, but I tend to agree with the second panel in the case of this patient. It illustrates that the ‘googling' was able to avert an unnecessary and irreversible surgery. This was not just an indiscriminate ‘googling' or searching of private information on Facebook pages. The action was prompted by very real concerns about contradictory information regarding the patient's medical history. On balance, the benefit of avoiding the unnecessary surgery probably outweighed the risk of harming the trust between the healthcare professional and the patient – one which was already undermined by the patient's deception.

This case is rather unusual because it is probably quite rare that a surgeon or a genetic counselor would find valuable information on a patient by merely searching Google or Facebook for information. The type of information that could be of value to most healthcare providers is not usually disclosed on public sites or social network pages. For example, a cardiologist may be interested in finding out why a patient's cholesterol levels are not decreasing despite being placed on optimal medications and being advised to cut down the dietary intake of cholesterol. The cardiologist may suspect that the patient is not really taking the medications or perhaps eating much more dietary cholesterol than the patient is willing to disclose during the doctor's visits. However, it is unlikely that the patient's Facebook page will chronicle whether or not the patient secretly eats cheese omelets on a daily basis or chooses not to take his cholesterol medications.

On the other hand, other healthcare professionals could find important diagnostic clues when reviewing the Facebook page of a patient. Psychiatrists or psychologists may be able to get a much better sense of a patient's mental health and functioning by reviewing the daily posts and interactions of a patient with friends and family members instead of just having to rely on the brief snapshot when they interview the patient during a 30 minute visit.

The study ""To Google or not to Google: Graduate students' use of the Internet to access personal information about clients." by the psychologists DeLillo and Gale surveyed 854 students enrolled in clinical, counseling, and school psychology doctoral programs in the United States and Canada, asking them how they felt about using Google or social networking websites to learn more about their clients/patients. Interestingly, two-thirds of the psychologists-in-training felt that it was never acceptable or usually not acceptable to use web search engines in order to find additional information about their clients. This feeling was even more pronounced when it came to social networking sites: 76.8% of the students thought that this was never acceptable or usually not acceptable.

However, despite these feelings, 97.8% of the students had searched for at least one client's information using search engines such as Google, whereas 94.4% had searched for at least one client's information using social networking websites. Importantly, 76.8% of the therapists who had conducted the searches for client information on social networking sites also reported that it was either always or usually unacceptable! This suggests a significant dissonance between the ethical perception of the therapists and their actions. Furthermore, more than 80% of the therapists who had conducted the searches said that their clients were aware of the internet and social networking searches they were conducting.

The case study with the patient requesting the mastectomy and the high prevalence of using the internet to perform searches on patients/clients by psychologists highlights the ethical dilemmas that are emerging in our culture of digital sharedom. The internet with its often very public display of individual information may be a powerful tool for certain healthcare professionals, but we also need to develop ethical guidelines for how healthcare professionals should use this tool. For medical procedures and tests, healthcare professionals have to obtain informed consent from their patients, discussing the risks and benefits of the procedure or test. Should healthcare professionals also obtain informed consent from patients before they pry into their social media networks? Or would that defeat the purpose because the patients might change the privacy settings or change the content of their posts, knowing that healthcare professionals might be reviewing them? Should healthcare professionals in specialties such as psychology and psychiatry ‘google' all their patients – just like they now ask questions about substance abuse to all patients – or only if there are certain red flags?

The survey of psychologists-in-training highlights the cognitive dissonance that healthcare professionals may experience: They may reject such searches on their clients or patients in the abstract, but they may still choose to perform the searches, probably because they think it will allow them to provide better care for their clients and patient. Instead of relying of idiosyncratic decisions made by professionals, we have to establish the ethical ground-rules for how healthcare professionals can use search engines or social networking sites when obtaining information about individuals. We may have become so accustomed to invasions of our privacy by government agencies and corporations that we sometimes forget that privacy is instrumental in maintaining our individuality. Especially in relationships that are founded on an extraordinary degree of trust, such as those between healthcare professionals and their patients or clients, we need to ensure that this trust is not eroded by the dark side of sharedom.

Acknowledgements: I would like to thank Ryan Hunt from CareerBuilder for clarifying the survey results. An earlier version of this article was first published on  the 3Quarksdaily blog.

  1. Rebecca Volpe, George Blackall, and Michael Green; and Danny George, Maria Baker, and Gordon Kauffman, "Googling a PatientHastings Center Report 43, no. 5 (2013): 14-15.
  2. DiLillo, David; Gale, Emily B. "To Google or not to Google: Graduate students' use of the Internet to access personal information about clients."Training and Education in Professional Psychology, Vol 5(3), Aug 2011, 160-166. doi: 10.1037/a0024441 Volpe R, Blackall G, & Green M (2013). Case study. Googling a patient. Commentary. The Hastings Center report, 43 (5), 14-5 PMID: 24092585 DiLillo, D., & Gale, E. (2011). To Google or not to Google: Graduate students' use of the Internet to access personal information about clients. Training and Education in Professional Psychology, 5 (3), 160-166 DOI: 10.1037/a0024441

1 comment:

  1. Social networking is public, if patients didn't want any of their healthcare providers or anyone else for that matter to see these profiles then there are measures they can take to do so. I believe that in case where there might already be suspicion or a physician thinks a patient is with holding potentially dangerous information for their health then there is nothing wrong with searching them on google or looking at their social networking profiles.