Thursday, February 23, 2012

A Letter to Potential Shrink Bloggers

So Shrink Rap has been up and running for a little while now, in April it will be 6 years.  Podcasts, twitter feeds, collateral blogs, a book, and by some small miracle, we've managed to do this, talk fairly openly about our work, and still (please, please, cross your fingers, knock on wood, and throw a shaker of salt over the dog's head) we've not gotten ourselves in trouble.  Our employers and chairmen and friends and relations know that we blog, and while we may have made a few cyber enemies along the way, it's mostly  been a really good experience.  We think there should be more shrinks out there blogging.  

Can I pretend I'm old and wise make a few suggestions for the younger ones in the Shrinky crowd who might be thinking about blogging? 

Dear Young Shrink (a resident or fellow, or early career psychiatrist, perhaps)--

So you think you want a blog.  

When we started blogging, we were all experienced psychiatrists.  I'll speak only for myself, but my experience of the practice of psychiatry has been a positive one: I like treating patients and most seem to get better.  People are often glad to see me and to tell me what's going on in their lives, and I am glad to see them.  I don't mind listening to people complain and I don't get tired of hearing their problems.

 When we started blogging, we learned about a whole other side of psychiatry through some of our commenters.  There are people who are angry with their psychiatrists, with the effects of the medications they'd taken, and who have felt injured and wounded by the treatments they'd received.  It can be a vocal and angry world, and while I've found it to be very educational and enlightening, and sometimes painful, I'm personally glad that I viewed psychiatry as a collaboration with generally good outcomes before I learned about this land where the psychiatrist and patient are adversaries.  I'm not sure it's the world we want our new initiates being inducted into-- it's like an agar plate to grow cynicism.

Having said that,  if you still want a blog, let me give you a few pointers.

It's not your diary, it's on the internet.  It's fine to use a pseudonym, but write every word with the assumption that your mother, your patients, your residency director, your next employer, and any malpractice lawyer representing a plaintiff might find it.  Or in the case of our blog---you may later decide to write a book.  There is no anonymity on the internet.  As the impulsive big mouth in our group, I decided it was safer for me to use my real name and not ever let myself forget that what I say is "out there."   If you wonder if you should post something, you probably shouldn't.  (Or you should ask your respected co-bloggers for their opinions).

Don't blog about your patients.
Don't blog about your patients. 
It was worth saying twice.

Even in the most ideal of worlds, some patients are difficult and there are bad days.  If you need a release for your own angry feelings, consider therapy, a good friend in your program, or a journal in Word (or another word processing program of your choice) that does not get openly posted to the internet.  Part of being a doctor means that you lose your right to vent in certain ways because no one wants to hear that doctors might not like their patients, and everyone (even me) hears these things and thinks "Does my doctor feel that way about me?"

There are moments when cynicism, sarcasm, and the totally politically incorrect world of Say-what-every's-thinking-but-never-wants-to-admit do work.  Samuel Shem's book, House of God, is one example and House, the current TV show about an opiate addicted hospitalist who spits venom at everyone, are examples, but then again, I Hate House.  I don't know why those examples worked, but maybe because House of God was so anti-Marcus Welby, and House is too ridiculous for anyone to take seriously.    They are both exaggerations.  If you try it on a blog, I think you'll get blasted, and be one more example of heartless psychiatrists who don't care about their patients, and that helps no one.

Put on a suit of armor before you start.  Learn to duck quickly.  Consider comment moderation.  Take a break, if needed, and stop if it's not going well.

Be considerate of the fact that people who are suffering from psychiatric symptoms may be reading your blog and try not to make their pain worse. 

And don't blog about your patients.  

Okay, we have time for a few questions.  


Simple Citizen said...

Thanks for the tips. I started a blog 2 years ago for book reports, political stuff etc. Now that I'm doing more journal clubs and article presentations I've started blogging about interesting or controversial articles I've read.
Any danger on giving opinions about medical journal articles?
Any risk of my writings being seen as medical advice for which I could get into trouble later?

So far (unfortunately) the articles I wrote about were about how medication doesn't work as well as many people think.

Anonymous said...

@Simple Citizen

On your blog, you identify yourself as a doctor. I think you need to put a disclaimer on there saying that your writings are general in nature and should not be construed as medical advice. Also that if anyone has any concerns about his/her health s/he should consult his/her own doctor for advice/treatment.

Maybe some of the doctors who read this blog could weigh in with more concise wording for a disclaimer?


Jackie (not a doctor)

rob lindeman said...

Anything a doctor writes, on any subject, in any forum or modality, can and will be read out in front of him in court, whether he writes anonymously or not. I know whereof I speak.

The question is, are you going to be too scared speak your mind?

Dinah said...

Simple Citizen: You could make someone mad, but that seems to be true when anyone expresses an opinion. If you work for the drug company that made the drug you're blogging about, it could be a problem to hold on to that job.

I believe the publisher put such a disclaimer in the front of our book.

I'm not a fan of such disclaimers because 1) it's obvious this is a blog and not personal medical recommendations, 2) We have topics such as Dinahrants, glow in the dark cats, pregnant pigs, and cell phone submersion-- it's clearly not
intended as medical opinions. 3) We do give some general suggestions, such as how to find a psychiatrist. Can you really sue a blogger if they lead you astray? 4) The number of things that one might say we should disclaim could be endless and meaningless.

Rob, there are some things I don't speak my mind about here because I don't want to hurt people, or I don't want to deal with the reaction I'll get, or it seems inappropriate. Most of the time, I'm just me and I say what I want to say.

Psych Client said...

I'm a patient not a doctor and although I've gone through my share of psychiatrists, I appreciate their efforts. I am that complex patient. I have attention and concentration issues, temporal lobe epilepsy, major depression, bipolar two, and lovely borderline traits. recently I've discovered through therapy I am dissociative as well. many reasons for me to want to throw in the towel.
I think in my case my psychiatrist s haven't wanted to work with my therapist he's a psychologist and has been with me six years.
I'm confused about why my two doctors won't work together. my therapist tries but it rarely works out so I keep looking for a psychiatrist who is willing to work with my therapist who knows me, has diagnosed me and knows my traumas, he's a good man.
I only get tips 15 minutes with my psychiatrist so its hard to fill him in with my history when medication is all we talk about.
I don't dislike psychiatry I respect the profession and most have their heart on the right place.
I like your blog, I haven't read everything but want to thank you for good information

frenetic said...

nothing of significant substance to add other than - well written. I liked that entry... oh, and don't blog about your patients. ;-)

Altostrata said...

Yes, there are a huge number of patients out there who have been injured by psychiatry, and some might find their way to a psychiatrist's blog and make bitter comments.

As an injured patient, I'm just as surprised you didn't know about this, Dinah, as you were to find psychiatry isn't universally acclaimed.

With all the questions about the validity of pharmaceutical psychiatry's research base, the obscuring of adverse effects and risks, the minimizing of withdrawal problems, how could you expect other than a large number of patient injuries?

Do clinical psychiatrists think all the scandal is merely academic?

Mickey Nardo just posted a beautiful apology to patients on behalf of all psychiatry here

Dr. Nardo retired and quit the APA in protest before he had to go into pharmaceutical psychiatry. He's spending his retirement taking apart studies to find out what -- and who -- went wrong, partly to make amends for the rest of his profession.

He says: "I was a Silent Witness to something pretty rotten, and I didn’t take the time or put in the effort to scope it out. So I share in the shame."

Would that other clinicians also realized that it isn't somebody else who's injuring patients. It's not those darn GPs, although you could say they're loading the guns. It was psychiatry who manufactured -- and I do mean manufactured -- the ammunition that's led to widespread overprescription and injury.

So if you do write a blog that presents prescribing risky drugs for arbitrary diagnoses as business as usual, you will attract patient naysayers. Sorry, that's the Internet for you, the injured get to contribute their reviews.

SteveBMD said...


As a fellow psychiatrist and blogger, I agree with what you write, and for many of the same reasons.

However, the widespread acceptance of blogs, Twitter, Facebook, etc. in modern culture should make us think about the evolving nature of "privacy" and self-disclosure.

I say and write things on my blog that, in a previous era, I might only have written in a diary. And, admittedly, I do occasionally write about patients, but I take great pains to omit identifying information, and some patient examples are actually amalgamations of several patients.

On the patients' side, some patients are incredibly open about their past; some even write and blog about it themselves! I participated in a TV documentary in which one of my patients invited a camera crew to follow his several-month-long struggle with alcoholism, and it turned out to be beneficial for him and for viewers (BTW, he's had >4 years sobriety now).

Why do we do these things? I can't speak for other medical specialties, but I think that in psychiatry we need to stop feeding the stigma that patients can't talk about their diseases, and doctors can't talk about interesting cases or failures. (Why can Oliver Sacks write about his interesting case of prosopagnosia or Capgras syndrome but I can't write about my patient with borderline personality? And don't say it's because I'm not Oliver Sacks. I know that!)

The internet has given us a wonderful opportunity to communicate in direct ways that were previously impossible. It has allowed me to express opinions that, hopefully, give readers an idea of what kind of psychiatrist I am. It has offered patients a platform to provide support to each other, complain (hopefully legitimately) about mistreatment, and tell us how to do our jobs better. Yes, we need to be careful with what we write, but we also should embrace the openness it provides.

Noel Bell Psychotherapist said...

Yes don't blog about patients. Read saying twice actually. Thank you.

Anonymous said...

No, SteveBMD, you can't blog about your patients in any way that would make their "case" recognizable which ends up meaning you can.t write about your patients. if you need to talk about your patients, get a supervisor. To doctors everywhere, you need to remember not to talk about your patients either. Not at home and not at parties. The only exception is to a supervisor or colleague from whom you are seeking advice.
It is not about stigma. It is about that thing called confidentiality and protecting patient privacy and if you are getting paid by a health plan or an individual to provide care, that is where your rights end, in terms of what you get out of the transaction. Doctors need to understand that saying that talking about something reduces stigma is false. It depends who does the talking. It depends on lots of things. Talking about erectile dysfunction in television ads may have helped more guys go to a doctor about it but I doubt they want the doctor writing about them and ED. Yes, the nature of privacy is evolving as a result of the internet but people choose to participate or not. You don't get to make the choice for them and perhaps we will see a backlash when people truly understand how their privacy has been eroded, including ways they can stop contributing to that trend.

SteveBMD said...

Anonymous (& others?),

I NEVER blog about patients currently under my care. That is a serious breach of ethics. Sure, I may write about "bipolar disorder" or "ADHD" in a general way while also treating patients with those conditions, but I would never write about those individuals specifically. I suppose that wasn't clear from my comment.

Anyway, regarding Dinah's comment "Be considerate of the fact that people who are suffering from psychiatric symptoms may be reading your blog and try not to make their pain worse," I couldn't agree more. When I write about conditions or symptoms (or even [anonymous] individuals), I try to do so in a compassionate manner that puts their needs and wishes first, and mine a distant second.

jesse said...

@SteveBMD and @Anon, Steve, you should not blog about patients even long after they were under your care. Anon is completely right about this and said it perfectly. You may well have a patient in mind when you write a vignette, but the details should be so disguised that the patient himself would not recognize that he was the model. That is the standard Dinah and the other Rappers use.

If you say "I at times blog about my former patients but it is disguised" you are inviting them to find themselves in what you write. There can of course be coincidence, and one patient's history might in fact resemble a constructed example. If a former patient thinks he sees himself in your example, and you have been holding out publicly that you do use histories of former patients in that way, you are just setting yourself up for trouble as well as having hurt the patient.

jesse said...

P.S. It is clear that SteveBMD is thoughtful and cares about his patients. It is often the case that such physicians put details into histories that are otherwise unnecessary because they are honest and habitually truthful. But in psychiatry a patient may be compromised simply by it being known that he is a patient. Remember the vice presidential candidate whose psychiatric history was exposed? Patients have a right to conceal that information or to reveal it, it is their choice, not ours.

What we put on the Internet is available to anyone. Yes, we should be able to discuss controversial topics but in everything we write we should ask ourselves how it would sound being read aloud in a public forum by someone with opposing interests at heart.

Anonymous said...

Writing about present and former patients on a blog -- or violating their privacy in any other manner -- is putting yourself at risk of a Federal lawsuit.


Anonymous said...

"Mickey Nardo just posted a beautiful apology to patients on behalf of all psychiatry here"

And he gets the authority to speak on behalf of "all psychiatry" from where, exactly?

Anonymous said...

out of curiosity, what about books like sybil or 3 faces of eve? how do documents like those transpire when there is such a giant risk to the patients privacy and mental health if their identity is revealed?

Anonymous said...

"out of curiosity, what about books like sybil or 3 faces of eve? how do documents like those transpire when there is such a giant risk to the patients privacy and mental health if their identity is revealed?"

Simplest answer is we have laws against murder but they don't deter everyone from committing murder. WRT Sybil, boundary violations occurred throughout the "treatment". That this book exists, does not make it right. There are other more recent books that have been collaborations between psychiatrists or therapists and their former patients. In those cases, one would hope that the patient participated and granted permissions that were not influenced by the desire to please the doctor or other unhealthy motives. If they did, it was their choice to forgo anonymity. We do not publish the names of rape victims, as a general rule but we also do not stop people who have been raped from coming forward with their experience in a public forum. Hospitals do not publish lists of those treated for mental or any other type of illness but people are free to self disclose in a public way. They are also free to try to maintain as much privacy as possible (not easy when the info about mental illness, suicide attempts etc finds it way into the hands of government agencies, and it does).

Bill Lynch said...

Great piece on blogging. More of us could, and in my opinion, should be doing this. The informality of blogging helps me actually write vs wish I would.
I plan to follow you and encourage you along the way.
William R. (Bill) Lynch, MD

Anonymous said...

Let me know your take on this a man is medivaced in tremendous back pain at a military hospital. The examiner a psychiatrist says the man has an upper respiratory infection, personality disorder, and unstable. They x-ray him tell him nothing found with his back. Two weeks later they said he walked in complaining of a back problem then they supposedly x-rayed him again this time they find that he has bilateral spondylolysis, spondylolisthesis, and shows eburnation of l5 on s1. The last part is falsified to coverup a training incident accident which included kicking the soldier in the spine. How is it that a psychiatrist is manning the er room on midnight. The soldiers records are cross out and many mistakes and incorrect info documented. The psychiatrist is one that currently practices pharmacology in DC. How do shrinks deal with records spoliation charges via personality disorders or what

Anonymous said...

@ Dinah, I'm a frequent reader of this blog ( I always appreciate that you share and wish commenters were sometimes kinder), but I personally have only commented once before. That comment was about how much I valued not knowing personal details about my therapist, even though of course I was curious. I came back to find that original post, and found this one instead. I'll comment here - it's relevant enough.

Okay, so mixed feelings. I love this blog and so many other resources because it has truly helped me demystify therapy (the scariest and hardest thing I've ever known in my adult life). I've been in therapy a year, and have had to disclose some terribly hard things to my very kind and patient therapist. For lots of reasons, probably mostly lack of trust and fear of doing it "wrong", I've been a sponge soaking up everything I can about therapy so I can feel more comfortable in my sessions and with processing all my past trauma, etc.

Well, I finally went onto my therapists website after all this time since starting to see him. And I'm a little shocked to find that he has completely changed his areas of focus (which do not include what I'm seeing him for) and he's also started a blog to talk about these other areas of focus. Within the blog, he talks about how very important it is for therapists to find clients that are in the therapist's areas of interest so the therapist remains engaged and excited about their work. There's much more - but that's the gist of it.

Oh man, I wish I didn't read that. Obviously this is something I might need to talk about in therapy. And maybe let settle in my own self as well. But before I do... I wanted to share in an anonymous space to get it out of my head...

I'm really for the first time wanting to quit my therapy and feeling like I'm nothing more than a well paying client. I always had a small nagging feeling that we weren't connecting, but I've ignored it because I'm much improved and he is rarely late to sessions and seems focused. Now I have to wonder if that nagging feeling was right all along. Plus, it's easy to chalk up the nagging feeling as insecurity, and totally normal.

Also, as I look back in time on his blog, I see ideas from his blog (example: what it's like to be right brained) that have been proposed in my sessions at the same time. Not sure if I inspired him or his blog inspired feedback in my therapy. But I think the latter, and that's a little disturbing, particularly when he doesn't talk much anyway. We're all human and I can see how it can happen, but still.

So... I'm just torn. A few days ago I was bragging to my friends how much I loved my therapist, and now those little occasional warning sirens inside are feeling justified, and it stinks. I don't think my therapist would never admit that my issues are... whatever they are to why he's not specializing in them anymore (depressing or too hard or too difficult), because that'd make me feel bad. But yet, maybe it's true. I am left wondering what's real.

Thoughts or feedback?

Related to this post -- Again, I love love love the blogs, but when it's YOUR therapist blogging it just really takes on new and personal meanings, even if very subtle. Not sure how you can avoid that really. I probably just need to not read it again and put it out of my mind...