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How would you handle information about a patient obtained from an Internet search? Take the quiz.
If we were to conduct a survey of readers’ responses to the quiz that follows, we would likely find a marked generational divide between those who believe that “patient-targeted Googling” is just another form of collateral information and those who think that Googling is just a new type of boundary crossing.1 The etiquette and ethics of the electronic revolution have been styled “digital professionalism,” and it is a field in flux as we see when we analyze the case consultation from the October 2016 issue.2
The case presented a mid-career psychiatrist, Dr. R, with a predominantly psychotherapy practice who is treating Ms B, a woman in her thirties who purports to have been a famous academic musician until she unjustly lost her career after a student accused her of sexual misconduct. Initially, the psychiatrist believes the patient is suffering from an adjustment disorder, but as the sessions proceed he begins to doubt the patient’s narrative. His best efforts to engage Ms B in more critical reflection on the events, or even offer up more factual details, fail. He entertains the idea of Googling Ms B to find out what really happened-ostensibly to move the stalled therapy forward. But first he seeks advice from his former psychology professor, who assures him that there is nothing unethical about the practice.
The quiz asks you to think about whether you agree with the professor’s advice and how in your own practice you would handle information about a patient obtained from an Internet search.
1. Assume you are the psychology professor. What do you tell Dr. R about the ethics of “Googling” Ms B?
Option A: Go ahead and Google; the Internet is public domain. This is one of the most common reasons or rationalizations-depending on your perspective-in favor of Googling a patient. It is technically true that the Internet is mostly public domain, but this assumes that the person conducting the search is “the public” with the prevailing mores and morals of their society and not a mental health professional who many ethicists believe should be held to a higher standard of conduct.
Option B: Don’t Google the patient; it’s a violation of HIPAA. This is often used to mechanistically intimidate practitioners into not Googling, although the psychiatrist is technically not “exchanging information” in that he is not disclosing any protected health information about the patient. But this reflexive turn to HIPAA shows the ambivalence of many who contemplate Googling, yet who instinctively believe it is intruding on a patient’s privacy or who fear the legal consequences of a violation.
Option C:Don’t Google the patient; it is a breach of the patient’s trust in the therapeutic alliance. This is the answer of many older psychiatrists as well as those who have strong psychoanalytic training or orientation. How and when the patient reveals her psyche in the therapeutic relationship is at least as significant as what is revealed, and taking such a shortcut betrays not only the patient’s trust but the integrity of the process.
Option D:Don’t Google the patient; instead search the major newspapers from the city where Ms B purports the events occurred. This raises a fascinating question. How is Googling ethically better or worse than searching the newspapers, the latter inarguably being public domain? Ask yourself if you picked up the morning New York Times and found a story about one of your long-term patients: would you read it, or would you first ask the patient for her permission? A survey published this year found that nearly 40% of psychotherapists had searched online for information about a patient, especially when-as in the case of Ms B-they felt they had been deceived. About the same percentage knew or supervised someone who had engaged in patient-targeted Googling.3 Earlier surveys that focused on psychiatrists found similar percentages.4 One study found that 60% of psychiatrists questioned in New York believed that patient-targeted Googling could be constructively utilized in psychiatry.5
2. The professor tells Dr. R there is no ethical reason he cannot Google the patient. Dr. R then asks if he should obtain informed consent from the patient to conduct the search.
In question 2, Dr. R is still struggling with the question of confidentiality and so brings up the equally fundamental ethical concept of informed consent and whether he should obtain it before searching.
Option A: No, don’t tell her. This undermines the entire psychological purpose of the activity and its ethical justification to find out the truth, so you could help her in therapy. This is an odd mixture of motives that are key in determining whether a search is ethical. The professor seems to be saying that the goal of Googling is not just to obtain the information but to use it psychologically to facilitate the therapy. It is this basis in beneficence that could provide the ethical counterweight to the breach of confidentiality.
Option B:No, don’t ask her permission, but you can tell Ms B later that you conducted a search to be better able to understand and work with her in therapy. This bends the beneficence toward soft paternalism and assumes that the patient will accept that the psychiatrist acted for her “good.” It is easy to see how this strategy, especially for this already embittered patient, might unwittingly have the opposite effect of reinforcing her immature defenses-she will continue to believe that all that has befallen her is the result of undeserved perfidy.
Option C:Yes, ask her permission out of respect for her privacy. This is a prudent choice and may be what Ms B desires with her insistence that she was such a renowned figure that her reversal of fortune was headline news. The only catch is that the truth the papers printed is far less glamorous than Ms B’s fantasy, and a stark confrontation of this discrepancy would expose the false self she is desperately holding onto in therapy. More simplistically, if she says no, Dr. R will have no information and must also deal with the unpredictable reaction of his patient.
Option D:Yes, ask her permission and suggest that you do the search together in your office during a session. This best respects the patient’s autonomy and privacy and probably also has the most therapeutic potential to enable Ms B to face the truth of her past. However, like option C, she can obviously refuse the suggestion, leaving the course of therapy even more impeded. Should Dr. R decide to Google Ms B, it is hard to see how he could constructively use the information or preserve the alliance given the way the information was obtained.
3. The professor tells you not only is it ethically permissible to Google Ms B but that you actually have an ethical obligation to conduct the search in order to provide appropriate care. Does Dr. R really have an ethical duty to Google Ms B, and if so, what is its nature?
Question 3 emphasizes the spectrum of ethical views on the subject, even among leading psychiatric ethicists.6
Option A: Yes, Dr. R has a duty to overcome his own negative counter-transference toward the patient. This locates the warrant for Dr. R to work through his own negative emotions toward Ms B to regain the position of therapeutic neutrality he needs to be effective in treating his patient.
Option B:No, Dr. R does not have an ethical obligation to Google the patient because doing so is a breach of physician-patient confidentiality. This is the most traditional answer at the other end of the continuum: Googling cannot be a professional duty because it directly contravenes the more fundamental obligation to respect patient confidentiality.
Option C: No, Dr. R has an obligation to work within the psychodynamic frame to empathically understand and effectively treat the patient. This offers a more sophisticated variant of the previous option. It locates the psychiatrist’s primary duty to maintain the boundaries of the therapeutic relationship, within which compassionate listening may enable the patient to find healing.
Option D: Yes, if Dr. R does not review information that could potentially prevent harm to the patient, and if she attempts suicide, he will not have done his duty to protect her and could be held legally liable. This is the even more extreme version of C and once again emphasizes the diversity of opinion on the practice. A psychiatrist who did not obtain clinically indicated collateral information such as previous treatment records or reports of significant others-with consent outside an emergency situation-would not have met the standard of care.
Since by analogy the Internet is a source of information about the patient, do we not also have a duty to consult it? One thing almost every practitioner along the Googling continuum agrees on is the need for more definitive ethical and legal guidance, and several organizations and experts have proposed professional recommendations.4
4. Now that Dr. R has this information, what should he do with it?
In the final question, Dr. R’s clinical reality intrudes on the professor’s pontifications. Dr. R searched the Internet for information about Ms B-and now how does he handle it in therapy? Sound clinical advice is found in a review article by Clinton and colleagues.7
Option A:Dr. R should tell Ms B that he Googled her and would like to discuss what he found, so they can engage in more productive work about her real problems.
Option B:Dr. R should tell Ms B that he Googled her and that she has a right to know what he learned, so she can make an informed decision about whether to continue in therapy.
Both options assume Dr. R did not seek Ms B’s consent before his virtual detective work, and each is an attempt to restore some measure of ethical equilibrium. Option A pleads that he did not seek her consent for her own good, while option B gives Ms B a chance to exercise her own self-determination even if the search is a faitaccompli.
Option C:Dr. R should not tell Ms B that he Googled her but should begin shifting the therapeutic approach from adjustment disorder to narcissistic personality disorder. Options B and C add a breach of truth-telling to the lack of consent. Most psychiatrists would scrutinize a clinician who changed his diagnostic impressions on the basis of news stories.
Option D:Dr. R should not tell Ms B that he Googled her; instead he should say that he had read about her in a newspaper at the time of the incident but recalled the details differently. This is prevarication, and the worthwhile therapeutic objective could be more honestly accomplished through Dr. R disclosing his search.
Working through the case scenario, the wisdom of the deontological stance of the American Psychiatric Association (APA) Ethics Committee becomes apparent.8 In its commentary on the Principles of Medical Ethics, the APA opines that what renders a decision to Google a patient ethically justifiable is the motive of the psychiatrist. To Google for the good of the patient may be acceptable, to Google to circumvent the hard work of interviewing, or for voyeuristic breaching of boundaries, or in the case of Dr. R frustration over a thwarted therapy, may well not be ethical. You decide.
Googling a patient is not, in and of itself, unethical. First and foremost, the Googling of a patient should be done only in the interests of promoting patient care and well-being and never to satisfy the curiosity or other needs of the psychiatrist. Also important to consider is how such information will influence treatment, and how the clinician will ultimately use this information. The psychiatrist should ask himself or herself these questions before resorting to a Google search.8
Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. She reports no conflicts of interest concerning the subject matter of this article.
1. John NJ, Shelton PG, Lang MC, Ingersoll J. Training psychiatry residents in professionalism in the digital world. Psychiatr Q. October 2016; Epub ahead of print.
2. Geppert C. To google or not to google? This is the question. Psychiatric Times. October 2016;33:57, 58.
3. Eichenberg C, Herzberg PY. Do therapists google their patients? A survey among psychotherapists.J Med Internet Res. 2016;18:e3.
4. Koh S, Cattell GM, Cochran DM, et al. Psychiatrists’ use of electronic communication and social media and a proposed framework for future guidelines.J Psychiatr Pract. 2013;19:254-263.
5. Deen SR, Withers A, Hellerstein DJ. Mental health practitioners’ use and attitudes regarding the Internet and social media. J Psychiatr Pract. 2013;19:454-463.
6. Genes N, Appel J. The ethics of physicians’ web searches for patients’ information. J Clin Ethics. 2015;26:68-72.
7. Clinton BK, Silverman BC, Brendel DH. Patient-targeted googling: the ethics of searching online for patient information. Harv Rev Psychiatry. 2010;18:103-112.
8. Ethics Committee of the American Psychiatric Association. Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Arlington, VA: American Psychiatric Association; 2016.