SAN FRANCISCO - Long before she entered medical school or started her psychiatry residency, Dr. Emily Gray grew up enmeshed in online social media. Something that seemed like a routine part of her life now presents professional problems she hadn’t expected.
"I’ve always been in an Internet age," said Dr. Gray, who co-led a group discussion about the Internet and social networking at the annual meeting of the American College of Psychiatrists. When she attends meetings of the American Academy of Child and Adolescent Psychiatry, the peers she meets there simply ask if she’s on Facebook as a way of staying in touch. As a young, single woman, she has even tried online dating sites, said Dr. Gray, a chief resident in psychiatry at the University of California, San Diego.
Dr. Emily Gray
Her peers aren’t the only ones who are online, however. So are her patients. And people who seek her out because they saw her profile online.
Social media began to produce problems with transference. She stopped Internet dating. She is considering creating separate Facebook accounts – one personal, one professional. "Psychiatrists need to be aware that public information that they enter online for dating or networking may be accessible to patients," she said.
While there are some steps that psychiatrists can and should take online to maintain boundaries, the best course of action is not always clear, and some things are beyond psychiatrists’ control, said Dr. Glen O. Gabbard, who co-led the discussion. Patients can comment online about psychiatrists, rate them, blog about them, find personal information about them, and even download a satellite image of a psychiatrist’s house if they want to.
"Privacy has become radically redefined," said Dr. Gabbard, chair of psychoanalysis and professor of psychiatry at Baylor College of Medicine, Houston. Plenary sessions at the college’s 2012 meeting will address some of these issues, he said.
Dr. Glen O. Gabbard
In a show of hands, nearly all the psychiatrists in the room indicated that they had received e-mails from patients, but only a few said they participated in social networking sites. There are both advantages and disadvantages to using e-mail, websites, and social media that psychiatrists need to think through even as the ways in which these tools are used continue to change, he said.
"Ten years ago, I would have said, ‘Don’t respond to e-mails from patients.’ Now, patients expect you to e-mail and text them. It’s a moving target," Dr. Gabbard said. Unfortunately, state licensing boards tend to think in absolute, black-and-white terms about "boundary violations" in ways that might be lagging trends in technology use, he added.
Some legal precedents suggest that responding to a patient’s e-mail message establishes some form of a doctor-patient relationship, but not responding to an e-mail does not let a psychiatrist off the hook. Any e-mail that’s received becomes part of a patient’s record whether the psychiatrist responds to it, another session participant warned. One participant who does a lot of forensic psychiatry work urged her colleagues to "never forget that every word of that e-mail that you get can be put in front of a jury in court."
Some psychiatrists said they tell patients that they will not accept e-mails, or have patients sign an agreement to limit e-mails to making appointments, and explain that this is because they value the interpersonal, face-to-face therapeutic relationship. When asked to be friends on Facebook, they explain that they have friendly feelings toward patients, but are not friends.
Others said it’s naive to think that patients will respect these boundaries. Some patients will text about suicidal thoughts, send lengthy e-mail diaries about their status, or ask for advice.
Electronic media are not always a problem; sometimes they help in psychiatrists’ work. Some participants said a few patients cannot tolerate in-person sessions and electronic media help them connect with therapy. One psychiatrist said she finds patients’ e-mailed journals helpful. Another uses the unwanted e-mail to explore why the patient felt comfortable writing it but not talking about its contents in person.
A psychiatry resident has used online chat rooms to do family counseling with family members on computers in different rooms, which changes the dynamics compared with having everyone in the same room, Dr. Gray said.
Several psychiatrists said Skype is a helpful means of doing telepsychiatry. One suggested using Skype for visual contact but turning off the computer’s audio and speaking to the patient simultaneously by phone to maintain privacy.
Published reports have described the usefulness of computer programs in treating patients with eating disorders, Dr. Sandra M. DeJong of Harvard Medical School, Boston, said in an interview after the session. Various kinds of electronic media are being used to remind patients with chronic mental illness when to take their medications. Online programs are available to treat adolescent depression or childhood anxiety.