Treating Patients with Respect

Readers of this blog know that I admire Randy Cohen's "The Ethicist" column in the New York Times Magazine. Yesterday Randy responded to a question that connects to confidentiality, the topic of this week's seminar in the first year Harvard Medical School "Medical Ethics and Professionalism" course that I'm part of the faculty for. What follows is the question and Randy's response, with my own additional comments interlaced in bold italics:

Some of my Facebook friends are medical students who post cellphone pictures of patients with what these friends believe to be comical maladies, with captions like “A 5-foot-9 Hispanic male walks into a bar . . .” under a picture of a patient with a piece of rebar piercing his abdomen. The postings don’t include faces or names but still seem questionable. Doesn’t this violate patient privacy? NAME WITHHELD, NEW YORK

Were these soon-to-be doctors engaging in such gallows humor only among themselves, it might be seen as a harmless way to cope with deeply disturbing situations. But although these med students rightly strive to disguise their human punch lines — no, sorry, their patients — that is insufficient. It is essential that those photographed are not identifiable to others, of course, but it is also important that the patient does not recognize himself online. It's not necessarily harmful for the patient to recognize himself in print or online. A current patient should have been asked for permission to use his "story" and ideally should have reviewed and commented the proposed material in draft. But for former patients this may not be possible. The rule of thumb I've used over the years is that a patient's next door neighbor shouldn't be able to recognize who is being described, and the patient himself should feel respected by what he reads.

A doctor should not embarrass a patient or otherwise add to his discomfort, a likely outcome should the patient encounter such an image. The chances of that happening increase as the injuries depicted grow more grotesque and less commonplace. How many 5-foot-9 Hispanic males are impaled with reinforcing rod? It will not improve the doctor-patient relationship when that Facebook image goes viral and the patient learns the doctor treats him like a cartoon. Randy hits the nail on the head here. This injury is one-of-a-kind. In addition to the potential distress from being used as a joke, the photograph could be seen by millions within days, or even hours - and the patient's name is likely to come out.

A doctor that I consulted acknowledges that battlefield humor can be a benign response to harrowing circumstances but tells me in an e-mail that “public displays of such humor on the Internet, along with photos that even if not identified could be identifiable, are inappropriate and unprofessional.” Randy's informant is exactly right. Gallows humor among the peer group can potentially discharge tension and, by relieving anxiety, allow the group to pay the right kind of attention to the patient. I'm most comfortable with this kind of humor when we clinicians apply it to ourselves rather than to our patients. But there's no way whatsoever that this photo should be put onto Facebook, especially as part of a joke.

There is a deeper problem. Rather than simply giving doctors sufficient emotional distance to function effectively, this sort of horsing around might harden their hearts, making them less able to regard a patient as fully human. Such a transformation is not inevitable, but it is worth considering, particularly in a doctor’s training. Unfortunately, we know that on average, idealistic first year students lose much of their idealism, and imbibe a hefty dose of cynicism, by the time they finish their residency. But the student's "inappropriate and unprofessional" posting of the photo creates the potential for an important teachable moment. The anxiety and perhaps horror triggered by the patient's injury represents a reaction physicians must learn to handle constructively. Making inappropriate laughter into a teachable moment is nothing new. In Genesis 18:13-14, Sarah, who is 90 at the time, laughs when God tells her she will have a child. God makes this into a learning opportunity - "why did Sarah laugh?...Is anything too hard for the Lord?" And many med schools do consider that, says the doctor I consulted: “At my own institution, our anatomy professor has paid great attention to this issue right from Year One, when students confront their cadavers in the gross anatomy lab, with a series of well-conceived educational efforts.” As I discussed in a post last year about cadaver ceremonies, this form of teaching about respect is now widespread. Experiential education of this kind reflects an important advance in how we teach about ethics!