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 CareerBuilder.com 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.

References:

1. Rebecca Volpe, George Blackall, and Michael Green; and Danny George, Maria Baker, and Gordon Kauffman, "Googling a Patient" Hastings 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

Whistling Pigs: German Adventures with Google Translate

Bilingual or multilingual friends can be quite annoying. Especially if you’re stuck at a social gathering with the ones who repeatedly mention their language skills and utter phrases such as ”Well, if only you could read this novel in the original, you would have a much more profound understanding of what the author wanted to express…..”. Or the ones who like to cite French, German and Arabic language newspaper articles and then remind you with a thinly veiled pomposity that you may have a very narrow view of the world if you only rely on English-language news.

Via Bert Kaufmann (Creative Commons license)

However, this latter group is becoming more rare, possibly because a formidable foe is taking the wind out of their sails: Google Translate. The excellent book “Is That a Fish In Your Ear” by David Bellos has a chapter entitled “The Adventure of Automated Language-Translation Machines”, which is especially thought-provoking, because it explains some key concepts about Google Translate and the future of automated translation.

If a user enters a text into Google Translate, the linguistic search engine scours the Internet for multilingual texts, ranging from official documents posted by the European Union to articles and books that are available online in bilingual or multilingual versions. Using pattern recognition algorithms and statistical methods, Google Translate matches words and phrases contained in the user-entered text with those found in the large online repository of previously translated texts.

The underlying assumption of Google Translate is that any new text requiring translation contains phrases and word patterns that have been adequately translated in the existing online collection of bilingual or multilingual texts. Anyone who has used Google Translate can appreciate the success of this approach. While old-fashioned automated word-for-word translation often resulted in garbled paragraphs, the pattern recognition method of Google Translate does a rather impressive job of creating intelligible translations within seconds. For better or worse, this tool permits news-addicts to follow international major news stories in real-time as they develop by reading Google Translate’s renditions of local media, without having to wait for translations by bothersome multilingual friends. Google Translate allowed us to receive up-to-date information from the Japanese media as the Fukushima catastrophe in Japan was unfolding, and it also allowed us to read newspaper articles and editorials written in Arabic by journalists in Egypt or Tunisia during the Arab Spring.

I have often tested Google Translate by letting it translate newspaper articles from my native German into English and found the translations to be remarkably accurate. The English translations not only convey the gist of the original German article, but also include lucid and accurate translations of details contained in the original articles. However, most of these German newspaper articles are fairly functional and terse in terms of the vocabulary and phrases that are used. The few times that I’ve entered German essays or editorials written by linguistically gifted authors into Google Translate, the outcomes have been rather comical, especially if the German texts contained idiomatic expressions, puns or proverbs.

This may not come as a big surprise, because the efficacy of Google Translate is heavily dependent on the presence of consistent patterns of translation in the bilingual text repository that it accesses. Figurative expressions and idioms may not be that common in the existing catalogue of Google Translate texts. Even if figurative or idiomatic expressions are present in the Google Translate database, the translators may have used very context-specific methods to translate the expressions. German idioms often reflect historical events or cultural traditions, often reaching back to medieval history. It can be challenging to translate these idioms into a language with a different set of idioms which reflect a distinct history or culture. Some translators may choose to translate an idiom in the German text with a matching idiom in the target language. Other translators, on the other hand, may instead focus on translating the imagery or historical associations evoked by the idiomatic expression. Inspired by Bellos’ book, I decided to choose some of my favorite German idioms and see how Google Translate would translate them into English.

The judgmental staff

• German original: Du kannst doch nicht den Stab über ihn brechen!
• Google Translate: You can not break the rod of him!

The literal translation of the German phrase would be “You cannot break the staff over him!“ and is not too different from the one suggested by Google Translate. However, without the proper historical context, the translation appears to be rather incomprehensible. The German idiom refers to the medieval tradition of a Stab (staff or rod) being a symbol of power, especially in a courtroom. A judge would hold the staff during a trial, but if the defendant was sentenced to death, the judge broke the staff, possibly indicating that the defendant’s fate was now beyond the judge’s hands. The expression is used today if someone pronounces a negative judgment or condemns a fellow person. This expression is used to emphasize the importance of necessary caution before making pre-emptive judgments that may have irreversible consequences. In our contemporary culture and immediate access to online information, we are often tempted to judge the words and actions of fellow humans. I like this German idiom because invoking the image of a judge breaking a staff and pronouncing a death sentence may help promote the ideas of restraint and introspection.

Itchy ideas

• German original: Du hast ihm einen Floh ins Ohr gesetzt.
• Google Translate: You have him put a flea in his ear.

Google does a fine job of providing a literal translation of this German idiom, but it does not necessarily convey its meaning. The idiom is used to describe an idea or thought that we may have heard and are unable to let go. I enjoy the image of the “itching flea” in the ear, because I often obsess about certain ideas and I feel that I cannot easily disassociate from these “itching” thoughts. I have occasionally seen the translation of this German idiom with the English expression “bee in the bonnet”, however, the sensation of “itching” is perhaps a more intimate and painful description of an obsession rather than the buzzing within a hat.

Illicit stupidity

• German original: Er ist dümmer als die Polizei erlaubt.
• Google Translate: He is dumber than the police allowed.

Let us be very upfront about this: It is not (yet) a crime to be stupid in Germany. We currently do not have Colonel Klink-type policemen patrolling the streets and administering IQ-alyzers to weed out potential offenders, even though this idiom may suggest that we do. In everyday parlance, this idiom expresses the frustration resulting from someone’s ignorant behavior or actions.

The joy of stealing horses

• German original: Mit dir kann man Pferde stehlen!
• Google Translate: With you is a good sport!

The literal translation of this German phrase is “I could steal horses with you”, and it denotes great friendship and trust. The punishment for being caught stealing horses in medieval times was quite severe and one would only undertake such a task with a truly trustworthy friend. It also implies that this particular friend is open to exciting adventures, and this may be the reason why Google Translate suggests the “good sport” translation. However, “good sport” misses the core ideas of deep trust and friendship that thieving comrades would need to plan the grand theft of horses. The English expression “thick as thieves” may be a more suitable match.

It comes down to the sausage

• German original: Jetzt geht es um die Wurst!
• Google Translate: Now it comes to sausages!

When describing critical decisions, we Germans do not strive for world domination as some Hollywood movies would like you to believe. The expression literally translates to “Now it comes down to the sausage!” and it conjures up images of our not-so-elegant cuisine which primarily consists of meat and potatoes. During traditional German county fairs and folk festivals, games were held in which young men or boys would compete for the coveted Grand Prize: a large sausage. The allure of this prize created this expression which refers to crucial life-defining moments.

Whistling pigs

• German original: Ich glaube, mein Schwein pfeift!
• Google Translate: I think my rocker!

This German idiom literally translates into “I think my pig is whistling” and is meant to signify tremendous surprise (i.e. “I am really, really surprised!”), because most German pigs do not have a habit of whistling. The Google Translate choice of “rocker” probably refers to the English expression “off my rocker” and is an example of the search engine’s pattern recognition of this German idiomatic expression, which may have been translated using the English language idiom “off my rocker” in some texts. However, “off my rocker” may not be the best choice, because it not only avoids the endearing images of whistling pigs but also because “off my rocker” tends to have a connotation of transient insanity, confusion or craziness, more than a state of marked surprise.

Mysterious Bohemian villages

• German original: Für mich sind das böhmische Dörfer.
• Google Translate: For me, the Bohemian villages.

The literal translation of the German phrase above is “These are Bohemian villages for me” and this German idiom is used to indicate a state of confusion, comparable to the English “This sounds like Greek to me”. This phrase was popularized during the Thirty Year War (1618-1648) which engulfed a large portion of Europe. Bohemia, which is now referred to as the Czech Republic, has always had a long-standing multi-lingual tradition due to the linguistic and ethnic diversity of its citizens. While Czech was the language of the majority population, German became a second official language and was widely spoken in Bohemia. The Bohemian Revolt is considered to be one of the triggers for the Thirty Year War. During this devastating war, armies marched through and destroyed numerous European towns and villages. Large portions of the civilian population were uprooted and forced to settle elsewhere. Amidst this chaos, many German-speaking soldiers or refugees ended up in Bohemian villages which had signs that were printed only in Czech, and thus may have had difficulties deciphering them. This wartime upheaval probably gave birth to the German idiom about mysterious or confusing Bohemian villages.

 The yoke of the yolk

• German original: Das ist nicht das Gelbe vom Ei!
• Google Translate: That’s not exactly brilliant!

Once upon a time, people used to love egg yolks. The egg yolk was considered to be the most nutritious and tastiest part of an egg. The German phrase “Das ist nicht das Gelbe vom Ei!” literally means “This is not the yellow of the egg” and is used as a way to express dissatisfaction, because the essence or the best part (i.e. the egg yolk) is missing. This idiom is still often used in contemporary German, but I wonder whether future generations will retain it. Since the adverse effects of high cholesterol on cardiovascular disease are highly publicized, many of us suppress our desire for cholesterol-rich egg yolks and instead opt for egg white omelets with a side of organic tofu.

Schadenfreude

Schadenfreude is a German word that probably needs no translation since it is commonly used by English speakers. It refers to the Freude (joy or satisfaction) that one feels in light of someone else’s Schaden (damage or misfortune).  It is by no means a purely German emotion. Most people have probably experienced Schadenfreude at some point in their lives, but perhaps it takes German bluntness to give this universal human emotion an actual name. I have to admit that I felt quite a bit of Schadenfreude, when I saw that Google Translate was giving rather inadequate English translations of the German idioms. I think my Schadenfreude about Google Translate’s failings is based on the fact that it does such a good job with most texts that it makes people who take some degree of pride in their bilingual or multilingual skills feel superfluous. When we see that Google Translate struggles with figurative and idiomatic expressions because they elude the statistical pattern recognition algorithms of Google Translate, it allows us to feel that human translation skills aren't obsolete yet.

While Google Translate’s algorithms may be able to perform the grunt work of translation, we still need quite a bit of human creativity to translate puns, jokes, puzzles and idioms. In its present format, Google Translate offers multiple potential translations of phrases and words. The English translations I chose for the German idioms above were among the most suitable options that Google Translate offered, but even these were not able to properly convey the meanings of the idioms. However, Google Translate is still in its infancy. It is very likely that its repository (or that of other pattern recognition based automated translators) will be substantially expanded over the course of the next years as increasing amounts of bilingual literary texts will be available online. Once this repository incorporates a variety of translations of literary texts, it may become more adept at offering appropriate translations of challenging idioms and figurative expressions.

My initial Schadenfreude about Google Translate’s failings is gradually being replaced by a sense of anticipation in regards to the evolution of online translation. We often enjoy reading translations of books, but we have to keep in mind that superb translations usually represent a composite piece of literary art, co-created by the author of the original text and the translator. When I compare multiple translations of an original text, I not only marvel at the creativity of the respective translators but I also appreciate how different translators interpret the original text by way of choosing how to translate the original. Offering a gamut of potential translations for certain phrases may give the reader a much better sense of what the author of the original text may have wanted to convey.

Instead of mainly awaiting the evolution and improvement of automated translators such as Google Translate, one could also consider exploring another possible avenue for online translation: The creation of collaborative translation platforms. Such a translation platform could build on the success of Wikipedia, where individual users are able to edit encyclopedia entries. Challenging literary texts or essays that are rife with idioms, puns and humor would be excellent candidate texts for a collaborative translation. An automated translator such as Google Translate could create a rough draft which would serve as a starting point. The Wikipedia-like platform would then allow multiple bilingual or multilingual users to edit the translations, ideally offering multiple translations of the more challenging expressions and phrases. As with Wikipedia, these collaborative translations would be performed on a volunteer basis. Original texts that are either in the public domain or are freely accessible to the public would be very well suited for such a platform, and the collaborative translations could be made available under a Creative Commons License.  Such an integration of automated translation and collaboration between numerous users would likely create a plethora of translations of beloved literary texts.

This article was originally published on The Next Web