(This article is adapted from my presentation in the medical bloggers’ panel at the Medicine 2.0 Congress on September 4 in Toronto, Ontario.)
To explain the danger of doctors writing anonymously online, I want to present the case of one of medical blogging’s first casualties, a pediatrician named Robert Lindeman (left).
Dr Lindeman went to Yale and then did his MD and PhD at Columbia. He worked at the Children’s Hospital in Boston, which is known as one of the best, if not the best, pediatric care facilities in the world. He now works as a pediatrician, with a specialty in asthma and pulmonary diseases, in Natick, which is an affluent suburb of Boston.
In 2002, a 12-year-old patient of Dr Lindeman’s died of diabetes complications -- a condition called diabetic ketoacidosis, in which the body essentially self-destructs because of a chronic lack of insulin. It’s most common in young patients with type 1 diabetes whose disease goes undiagnosed and untreated. The 12-year-old, whose name was Jaymes Binns, saw Dr Lindeman at his Natick office six weeks before he died. Dr Lindeman didn’t diagnose Jaymes with diabetes. The family sued.
Meanwhile, there’s another aspect to this story. Dr Lindeman, who’s smart, gregarious and funny, loves to write. And he’s a good writer. Being a doctor is what he knows, and they always tell you to write what you know, so he wrote what he knew. In 2006 -- the Binns case still unresolved -- he got on the internet and started a blog. You may not have known Dr Lindeman’s name before, but many will recognize his former nom de blog: “Flea.”
Last year I wrote an article for the National Review of Medicine, titled “” about the growing doctor blogging phenomenon, and I talked to Dr Lindeman.
He explained to me that Flea wasn’t just a blogging pseudonym -- he was a sort of alter ego, to some extent. What Dr Lindeman couldn’t say, Flea could -- and did. Dr Lindeman told me:
“There has been a certain amount of blunting of messages that are difficult for a doctor to say. For a pediatrician to say most visits to a pediatrician’s office are unnecessary, for example. It’s a stupid thing for a person practising medicine to say, but Flea could say it and explain why and make an argument.”
(A transcript of my interview with Dr Lindeman is available here.)
Flea became a fixture of the medical blogging world. He became popular, known for straight talk, for saying the kinds of things that I think a lot of doctors wished they could say.
Fast-forward now a little bit, to spring 2007, Suffolk County Superior Court, in Boston.
The Jaymes Binns case didn’t settle and it eventually reached trial. Throughout the proceedings, Dr Lindeman is sitting in the courtroom and at the end of the day, he goes home and Flea starts blogging.
I’ll read to you a few things Flea wrote about the case. This is from his notes on jury selection:
“The jurors really really didn't want to be there. The poor young woman sitting in seat number one looked as though she wanted to jump out the window when she realized she was actually going to be impanelled. Some of the jurors appeared to be sleeping by the end of the selection process. Flea trusts they will remain awake during the actual proceedings.
“Flea was able to form an opinion of the plaintiff's attorney (we'll call her Carissa Lunt). Attorney Lunt has not an ounce of fat on her body. Her features are sharp and angular and not particularly pleasant. You don't get a warm and fuzzy from her. She has no sense of humor. You know when you overhear someone chit-chatting and she tries to say something funny and it really isn't and nobody laughs? That's her. Attorney Lunt bites her fingers. In court. She's a finger-biter. Wonder if she's a pillow biter too?”
You get the idea. It’s not pretty. (In fact, I opted not to read these things out loud at the Medicine 2.0 Congress last week.) And that wasn’t all -- Dr Lindeman also discussed and reproduced some of his communications with his lawyer about their preparations and defense strategy.
One blogger, Eric Turkewitz, a malpractice lawyer in New York who writes at NewYorkPersonalInjuryAttorneyBlog.com, at the time how dangerous Flea’s blogging was, and wondered whether he would be found out, and what the result would be, whether the blog could be introduced during the trial. Well, it turned out Mr Turkevitz was prescient.
I’ll read briefly from a on what happened:
It was a Perry Mason moment updated for the Internet age.
As Ivy League-educated pediatrician Robert P. Lindeman sat on the stand in Suffolk Superior Court this month, defending himself in a malpractice suit involving the death of a 12-year-old patient, the opposing counsel startled him with a question.
Was Lindeman Flea?
Flea, jurors in the case didn't know, was the screen name for a blogger who had written often and at length about a trial remarkably similar to the one that was going on in the courtroom that day.
In his blog, Flea had ridiculed the plaintiff's case and the plaintiff's lawyer. He had revealed the defense strategy. He had accused members of the jury of dozing.
With the jury looking on in puzzlement, Lindeman admitted that he was, in fact, Flea.
The next morning, on May 15, he agreed to pay what members of Boston's tight-knit legal community describe as a substantial settlement -- case closed.
Just like that, Dr Lindeman became the poster boy for the legal dangers to doctors of blogging.
After the case ended and the
Globe article came out, Flea disappeared and a lot of physician-bloggers were left shaking in their scrubs.
I asked Dr Lindeman about what effect he thought his case had on other doctor bloggers, and he said:
“The scuttlebutt I have been hearing is that it has had a chilling effect, and that makes me feel terrible. I try not to think about it, it makes me feel so bad that I am responsible. I’m inclined to think it is true, but I desperately hope it’s not true.“
But it was true -- the chilling effect was real. All of a sudden, the dangers of blogging became a hot topic in the medical journals. The
Canadian Medical Association Journal and the both recently ran articles about the dangers of blogging.
The
CMAJ’s article was titled “” I’m not entirely sure the authors had a grasp of the subject matter all that well -- isn’t online blogging redundant? -- but they sure as hell made blogging sound scary. Listen to this part:
“Why would you, as a physician, put yourself in a precarious position by posting personal feelings, opinions, and attitudes on a public website? Material that may seem innocent enough at the time of posting may come back to haunt you at any point in your career, by any person you have or have not yet met — weeks, months, years or even decades down the road. And, you cannot know who may have — or develop — a grudge against you. The people you may be writing about are patients with illness. They may be emotionally vulnerable or even unstable. As such they may seek to contact or confront you outside the work place. Giving those people a permanent electronic record about yourself may allow them to pursue you in ways you will not like.”
What exactly are they warning about? Has any doctor yet been stalked by a blog reader? Certainly not that I've heard of.
Anyways, my message is that all those dangers the academics are warning about are overstated.
I have a theory about the Flea case that I think explains where all the blogging fear comes from, and it all comes down to anonymity. Instead of protecting Dr Lindeman, the attempt at anonymity ended up ruining him. Here’s my diagnosis of Lindeman.
People liked reading what Flea had to say, they called him brave, they called him bold. He won a medical blogging award in 2006. My reading of the situation is that Dr Lindeman was having a good time, that he was enjoying it. I think it’s clear that Lindeman got emboldened and went further than he might have been if he had not been anonymous.
I think the most telling piece of information here is that Flea rather oddly referred to himself in the third person, a sort of weird Bob Dole thing. Maybe that doesn’t mean anything, but I think -- maybe not consciously -- Dr Lindeman saw Flea as somehow different than him. If you’re so inclined, it’s still possible to track down a full record of Dr Lindeman’s blog, even though he took it all offline last year. If you take a look through all his posts, you’ll notice a lot of photos and illustrations of scantily clad women and unnaturally busty female cartoon characters. Is that something a well respected Columbia University MD/PhD who publishes in academic journals would do if he thought readers would find out it was him? Certainly not.
When we were talking about his writing on malpractice law, Dr Lindeman told me, “The reason I blogged about it was to bring the id out into the public, to explain that this is something we are consumed with.”
I think his mention of the Freudian concept of id is appropriate to his case -- his id, which he called Flea -- got the better of him and (if you’ll forgive me for continuing this line of pop psychology thinking a bit further) his id dominated and eventually conquered his superego. And look what happened to him.
Another lawyer-blogger, a Texan named William J Dyer, had a similar diagnosis last year when the story broke. In a post titled “” Dyer wrote of Dr Lindeman’s folly: “Willful but subconscious self-destruction, possibly coupled and overlaid with a God-complex.” The runaway id, again, in a way.
As I said before, Dr Lindeman is a smart guy in many regards but in some ways he’s not always a very polite or prudent guy. Here’s what he told me about writing, when I asked him to think back about his experience:
“Anytime you write something in print, you need to expect someday it is going to be read to you in court. The most innocuous thing I ever wrote -- it was a description of the immunization schedule, on my official website -- was read to me by the attorney to make me look like a schmuck. How much more so something incendiary, then? No wonder when doctors write they write namby-pamby noncommittal crap -- it might get you in trouble someday.
“One solution is not to write at all. I’m not sure if it’s possible to be careful -- that’s the reason why I told you about the immunization schedule. I bristle at the suggestion that there’s a way to do this that is right, if by right you mean safe. Writing as a physician is a dangerous activity, and that’s a shame. That’s a message I’d like the folks to know. For physicians, writing is dangerous and there is something really messed up about that.”
But Dr Lindeman is wrong, and I think if you really pushed him to admit it, he would say that the real problem, ironically, was the anonymity.
The lesson from the Flea saga is that the real danger is not writing -- it’s writing anonymously. Anonymity gives you licence -- or at least, it feels that way -- to write about things you know you really ought not to be writing about at all -- like protected information about your preparations for a malpractice trial, as in Dr Lindeman’s case, or about a specific patient who could potentially be identified because of your writing. When you’re anonymous, it’s far too easy to say something without regard for its potential consequences to you -- the assumption being, incorrectly, that there will be none.
Anonymity online is all but impossible nowadays, and many internet users have been slow to realize that. And it’s not just people without internet experience: remember a few years ago when
The New Republic’s Lee Siegel got caught posting supposedly anonymous comments praising his own writing under the name “sprezzatura”? When I was writing my article on doctor-bloggers, I managed to get the names, addresses and phone numbers of a handful of Canadian doctors who thought they were anonymous -- at least one of whom wasn’t very pleased to hear from me and refused to comment. It only took me a short amount of time to get that information, and I’m just a journalist at a small Canadian magazine with no special computer programs or knowledge.
But things are looking up. According to a , released last week by Envision Solutions, the number of health bloggers writing anonymously has dropped by nearly half from 2006 to 2007, from 38.7% to 19.7%. The report’s authors attribute the decline to the Flea case, and another case involving an Australian surgeon who shut down her
Barbados Butterfly blog in 2006.
I’m happy to report that despite the scandals and the widespread warnings from academic journals, it seems like the number of doctors getting into blogging keeps rising, and I think that’s a good thing.
Jeffrey Goldberg, an excellent writer currently with
The Atlantic, when he began blogging earlier this year, posted this :
“Friends tell me that I will take naturally to blogging because I am in possession of many poorly considered opinions about issues I understand only marginally.”
As someone who also has many such opinions, I say: good! Doctors’ opinions are valuable. But doctors’ opinions have been conspicuously missing from public discourse, during an era in which healthcare delivery and health policy are increasingly important to the public, and when the public is better informed about medicine than ever before. Whether doctors’ blogs are filled with poorly considered opinions, or long-form researched essays, or crass jokes, or political polemics, or what have you -- all of those things are valuable because they encourage discussion and debate.
Whether a doctor’s blog helps by letting her vent a little bit or letting you explain how she feels, or if your topic is primary care remuneration, or health insurance law, or, as in Flea’s case, tort reform -- whatever the subject, blogging is a positive development in medicine and something that doctors should not and must not abandon because of some medical association analysts’ largely unfounded fears. So blog away, doctors... just don’t do it anonymously.
Photo: Robert Lindeman,