This study supports several observations. First, medical blogs are now part of the literature and media of medicine. These media include professional and scientific publication and presentation, medical stories and medical dramatizations in books, movies, theater, radio, and on television. Although medical blogs are a new addition to this list, the rapid increase in the use of the Internet suggests that their importance will grow. Medical blogs differ from traditional medical media because any person with Internet access can author a blog. This ease of use disconnects blog content from the editorial process common to books, journals, and conventional broadcasts. For the most part, blog authors have few incentives to maintain their credibility and integrity or, in contrast, to compromise it for the sake of ratings or sales.
Second, medical blogs are part of the public face of medicine. Whether or not blog authors are genuinely members of the health professions, they represent themselves as such and are likely to be seen as such. Most medical literature is subject to rigorous peer review and typically reaches only internal audiences. Other forms of medical communication, such as presentations at medical conferences or articles in the lay press, adhere to specific standards of content and decorum. In contrast, medical blogs are public documents written in a diary style typically used for private thoughts. The authors of some medical blogs censor their thoughts and comments less than we expect they would in traditional public settings.
Third, medical blogs derive their credibility from their relationship to the health professions, and therefore reflect on these fields. According to the American Board of Internal Medicine,
19 professionalism requires prime respect of the physician–patient relationship, strict adherence to patient confidentiality, and appropriate management of conflicts of interest. However, some blogs include unprofessional tone or content, such as negative comments about patients or the profession, violations of patient privacy, or promotion of special interests.
Overt violations of patient privacy are rare, but authors who provide information about their location or subspecialty may still be identifiable to their patients, colleagues, or the public. When these authors discuss their interactions with individual patients, they compromise their patients’ privacy. Even when the author is anonymous, detailed descriptions of patient interactions and conversations have the potential to be recognizable by the parties involved. For example, the anonymous blog author “Flea” revealed details of a patient’s death after a malpractice case was brought against him.
22 The lawyer for the plaintiffs recognized the description of the case, and shortly thereafter, the case was settled out of court and the author removed his blog from the Internet.
Some authors may compromise their professionalism because they fail to reveal conflicts of interest. A recent survey reveals that 29% of blog authors have been approached by public relations professionals to endorse specific products, and 52% of them have written one post endorsing such products in their blog content.
23 These endorsements are not advertisements that appear on the website; they are written into the blog narrative, often without any acknowledgement that they are paid promotions. Although we did find blogs that promoted health care products within their entries, we were unable to determine whether these were paid endorsements, because we found no disclosures indicating authors’ conflicts of interest.
While these observations might signal alarm, there is also reason for optimism. Public health communication has been associated with changes in populations’ behavior, such as reduction in smoking prevalence or increased condom use.
24 Medical blogs provide a new route for communicating substantial, evidence-based health information to the public. Many blogs emphasize positive elements of the practice of health care. Most prominent blog authors maintain their own anonymity, their patients’ privacy, and a respectful tone, thereby setting an example for new writers. A voluntary movement by medical blog authors toward self-regulation regarding patient privacy, transparency, anonymity, and patient respect is taking shape.
25–28 These mechanisms of self-regulation are key to maintaining professionalism and trust.
Medical blogs also give voice to clinicians whose points of view might never otherwise reach an audience. Nurses and physicians facing challenges or isolation at work use blogs and online communities to connect to peers who can provide advice and support. This network may improve the retention of health professionals, particularly in rural or other settings where it may be difficult to find peer support. In addition to exchanging comments on one another’s blogs, authors organize and participate in forums such as weekly blog “Grand Rounds,” and annual, in-person conferences.
This study has several limitations. Our snowball-style sampling missed an unknown number of medical blogs that are not connected via a blog aggregator or blog link. However, our method aimed to find the blogs most accessible to the public, and blogs identified were the same blogs mentioned in the lay literature and revealed by Google search. We also sampled blogs during a single year and sampled only five entries from each blog. Over time, we expect the number and complexity of medical blogs to increase. We included only blogs in which the author represented himself or herself as a physician or nurse. We did not sample blogs written by other health professionals, and the authors’ self-representations could be inaccurate. Nevertheless, as we have discussed, the blog’s effect may be the same whether or not this representation is true. Because many blog authors remain anonymous, we are unable to further differentiate characteristics of authors such as location or practice setting. We did not use content-analysis software, although our alternative method showed good agreement between reviewers and differences were resolved by discussion and additional review. Of note, the two categories with less reviewer agreement, “positive comments about patients” (kappa 0.5) and “positive comments about the health care profession” (kappa 0.4) may indicate that interpretation of “positive” can be difficult. For example, many “positive comments” could also be viewed as patronizing in tone.
The prevalence and visibility of blogs provides a new route for health communication and contributes to public perceptions of the health care professions. These new channels can give voice to a wider range of professionals and allow these professionals to reach broader audiences. They also risk exposing the public to unprofessional content and tone, privacy violations, and hidden promotions that damage the integrity of the medical field. Although there has been some discussion in the lay press regarding the ethical questions posed by medical blogs, there has been no organized or official response from the medical profession. Further research should examine the potential positive and negative impacts of medical blogs and the evolution of medical blogs as they are scrutinized by the scientific community and the lay press. Through consultation with blog authors, professional organizations should provide standards for blog tone and content. There are existing models for such standards, which would encourage health professionals to respect their patients and their profession in their writing.
25–28 Physician-leaders and medical educators should consider curricular development and educational forums that address the challenges, opportunities and responsibilities that medical blog authors face, and the place of this new medium within norms of medical professionalism.
1,2 Elinore J. Kaufman,1 David A. Asch, MD,2,3 and Katrina Armstrong, MD, MSCE1,2
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