The Internet has given physicians the ability to expand their professional networks beyond the four walls of a hospital or physician practice to a limitless pool of colleagues from across the globe. Discussions that used to take place around water coolers and in doctor’s lounges have moved to online message boards, blogs and social media sites.

But the Internet has also given some physicians an outlet to unleash vitriolic commentary many would never consider unleashing on a colleague in person.

Two physicians and a nurse practitioner witnessed this type of interaction first hand when a blog post about nurse practitioners and scope of practice – a topic which most physicians have strong opinions about – led to an online battle of words and opinions that turned hateful and threatening. They used this incident as a launching pad for an Aug. 29 Health Affairs blog post in which they offered up guidelines physicians should follow when engaging in online commentary.

The guidelines offered up by Matthew Freeman, a nurse practitioner, and Drs. John Schumann and Anna Reisman, an internist and family physicians, respectively, offered these suggestions for keeping online discussions civil:

  • Anecdotes are fine, but avoid drawing generalizations from one story. (“We had that dumb NP once. She didn’t know where the gallbladder is located. So NPs must all be dumb.”)
  • Identify the underlying emotion of a comment that irks you, and name it when you respond. (“Doctor Strangelove, it sounds like you’re frustrated that NPs have fewer hours of training and are asking for the same salary as MDs. Here’s my take: ….”)
  • Name-calling is out. Polite, respectful comments are more likely to be taken seriously, and to stimulate a productive conversation. ( “SJ, I appreciate hearing your viewpoint. Here is why I disagree with you.”)
  • Own your comments. Instead of making broad generalizations, make it clear that you are offering your opinion. (Rather than saying, “NPs simply should not be practicing without some sort of physician supervision,” say “I don’t think NPs should practice without any physician supervision.”)
  • Consider phrasing your comment in the form of a question. (“I’m troubled by the thought of NPs working in a rural area with no access to collaborating physicians. Does anyone have experience with that?”)
  • Go for the win-win. (“The demographics, economics and politics of health care reform suggest there’s enough pie for all of us in the primary care world. We are all undervalued and overworked. By uniting in cause and working with each other, both groups stand to gain in terms of creativity, relationships, and (dare we say) income.”)
  • Find the best alternative to a negotiated agreement. (“NPs are here to stay, with increasing autonomy across more and more states. Let’s find a way to work together—whether you’re a doctor or NP, our end goals are the same.”)
  • David Williams, president of Heath Business Group, a Boston-based health care strategy consulting firm, who writes the Health Business Blog, agrees that guidelines are needed. But, he said, an obvious suggestion was missing from the Health Affairs article: Use your real name.

    “The simplest guideline is to encourage people to identify themselves rather than hide behind the mask of anonymity,” Williams wrote in a Sept. 4 blog in response to the Health Affairs piece.

    Many newspapers took a step beyond just encouraging people to use their real names by moving to a Facebook-based login system. Each comment is linked to a Facebook profile, therefore no one can remain anonymous. But Williams doesn’t think that is the best solution.

    “I allow anonymous comments on the Health Business Blog because I understand that not everyone wants to add to Facebook's data mining trove by logging in to make a comment, and because sometimes there are reasons to remain anonymous,” Williams said. Employed physicians, for example, may not be able to express their opinions openly as an employee of a hospital or health system.

    “However, I am quicker to delete anonymous comments that aren't constructive, and when I reply to anonymous comments I often point out that anonymity undermines the commenter's credibility,” Williams said.

    Schumann said the recommendations were meant for a world in which anonymous comments are allowed.

    But, “It does makes sense to have commenters take ownership of their comments by being permitted to post only with identification. No doubt that would go a long way toward minimizing vitriol,” he said.

    Several medical societies, including the American College of Physicians and the Federation of State Medical Boards, have developed policy on online behavior among physicians. Those policies tend to focus more on physician-patient interactions and not physician-physician interactions. Policy developed by the ACP and the FSMB calls on physicians to act professionally and warns agains anonymity. Policy developed by the American Medical Association calls on physicians to monitor each other for professionalism.

    The policy states, “When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.”

    Additional Resources:

    “Doctors and the Bully(ing) Pulpit,” Health Affairs, Aug. 29.

    “A Simple Rule for Online Comments: Use Your Real Name,” Health Business Blog, Sept. 4.

    “Professionalism in the Use of Social Media,” American Medical Association.

    “Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards,” Annals of Internal Medicine.