Letters to the Editor

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May 1, 2013 Volume 77, Number 5
Letters to the Editor

@Dr. Ting#Anesthesiology #SocialMedia #Privacy and Professionalism Warning! Dr. Ting’s article about social media and anesthesiology in the March 2013 issue, “Join the #Anesthesiology Conversation Online,” fails to address a key aspect of social media in the professional setting. There is no doubt that the responsible use of social media allows anesthesiologists easy access to continue their education, stay connected, advocate and communicate for themselves, their practice or their organization. However, the online universe is fraught with potential hazards for practitioners, namely the erosion of personal-professional boundaries for practitioners and the risk of inadvertently revealing patient information. It is imperative that every article about the advantages of online social networks clearly address these risks.

Physician use of social media is approaching 70 percent.1 Increasing numbers of anesthesiologists have at least one social media account, but they may be unaware of their privacy settings on those accounts, since they are not expecting potential patients to view these sites. Loose privacy settings may allow employers, hospital administrators, attorneys, or patients unintended access to the personal life of the anesthesiologist. Images containing obvious drunkenness, inappropriate social activity or generally unprofessional conduct may be very detrimental to the anesthesiologist’s online and real-world professional standing.2

Online social networks create a seemingly protected space for discussion of interesting cases or situations with professional colleagues. Few practitioners may be aware of the 18 HIPAA identifiers that may reveal unintended patient information to the online universe (yes, there are 18!).3 Strict adherence to these rules would suggest that all information related to patient care has no place for discussion or posting in social media.

Governing bodies in medicine have established guidelines cautioning physicians to maintain “appropriate boundaries of the patient-physician relationship” and “encouraging they consider separating personal and professional content online.”4 The FSMB has published guidelines suggesting “parity of ethical and professional standards applied to all aspects of a physician’s practice, including online interactions through social media and social networking sites.”5

Social media provides an excellent means of educating, connecting and communicating. Caution must be taken by anesthesiologists to separate their professional and personal lives online. Awareness of the 18 HIPAA identifiers must inform all communications and postings to social media sites. As Dr. Ting suggests, it is time to join the #Anesthesiology conversation online. It may be best to join after heeding the #privacyandprofessionalism warning.

Ryan Gibb, M.D.
Albany Medical Center, Albany, New York

Arup De, M.D., M.B.A.
Albany Medical Center, Albany, New York

1. Modahl M, Tompsett L, Moorhead T. Doctors, patients & social media. QuantiaMD website. http://www.quantiamd.com/q-qcp/DoctorsPatientSocialMedia.pdf. Published September 2011. Accessed March 6, 2013.
2. Thompson LA. Dawson K, Ferdig R, et al. The intersection of online social networking with medical professionalism. J Gen Intern Med. 2008;23(7):954-957.
3. HIPAA privacy rule and public health: guidance from CDC and the U.S. Department of Health and Human Services. CDC website. http://www.cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm. Accessed Mar 6, 2013.
4. Report of the Council on Ethical and Judicial Affairs: CEJA Report 8-I-10: Professionalism in the use of social media. American Medical Association website. http://www.ama-assn.org/resources/doc/code-medical-ethics/9124a.pdf. Accessed March 11, 2013.
5. Special Committee on Ethics and Professionalism. Model policy guidelines for the appropriate use of social media and social networking in medical practice. Federation of the State Medical Boards website. http://www.fsmb.org/pdf/pub-social-media-guidelines.pdf. Published in 2011. Accessed March 6, 2013.

Response from Dr. Ting
I agree that we, as doctors, should be responsible and think about what we are communicating and realize that things we make public are indeed public. This is true about everything we do and not just about social media. We should not be discussing specifics about our patients in any public manner, whether a conversation in the elevator or a conversation on social media.

I appreciate the comments from Drs. De and Gibb, which remind us of these principles. However, I find most practitioners err on the side of too much caution when it comes to social media and end up avoiding it altogether, rather than not enough.

Paul H. Ting, M.D.
Charlottesville, Virginia

Speaking Up About Intraoperative Handoffs
We read, with great interest, the article “Best Practices for Handover Communication” by Dr. Singh-Radcliff in the March 2013 ASA NEWSLETTER. Handovers, or “handoffs,” are indeed an important yet frequently overlooked component of patient safety, especially in the perioperative setting. As Dr. Singh-Radcliff notes, handoffs between anesthesia providers and the PACU team or ICU team are critical communication exchanges that should be formalized to maximize completeness. There is, however, another perioperative handoff scenario that occurs very frequently but has drawn less attention. Specifically, we are referring to intraoperative handoffs between anesthesia providers during transitions such as shift changes.

There is very little literature addressing the practice of changing anesthesia personnel during surgery. An early study by Cooper et al.1 suggested that errors potentially leading to critical incidents could either be caused or prevented by a change in anesthesia providers. Other studies surveyed anesthesia providers and concluded that there was dissatisfaction with current handoff procedures, and there were suggestions that they should be formalized and documented.2,3

In today’s technological age, with the widespread availability of electronic health records (EHRs) and anesthesia information management systems (AIMS), a.k.a., electronic charting, it would seem logical to incorporate such a handoff procedure within these frameworks. Indeed, such an intraoperative handoff protocol has been created and implemented at Washington University in St. Louis.4 In this example, the handoff tool directs both the incoming and outgoing providers through a checklist of relevent items. The EHR and AIMS are integrated into the tool by automatically populating specific items and then serving as a deposit for documentation.

In conclusion, Dr. Singh-Radcliff has highlighted the importance of quality handoffs as anesthesia personnel transfer care of patients to other settings and health care providers. However, intraoperative handoffs between anesthesia providers are another potential source of communication failures and therefore equal efforts should be made to optimize them as well.

Jens Tan, M.D.
MD Anderson Cancer Center, Houston, Texas

Daniel Helsten, M.D.
Washington University in St. Louis, St. Louis, Missouri

1. Cooper JB, Long CD, Newbower RS, Philip JH. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology. 1982;56(6):456–461.
2. Horn J, Bell MD, Moss E. Handover of responsibility for the anaesthetised patient - opinion and practice. Anaesthesia. 2004;59(7):658–663.
3. Jayaswal S, Berry L, Leopold R, et al. Evaluating safety of handoffs between anesthesia care providers. Ochsner J. 2011;11(2):99–101.
4. Tan JA, Helsten D. Intraoperative handoffs. Int Anesthesiol Clin. 2013;51(1):31-42.

Response From Dr. Singh-Radcliff
I applaud the letter from Drs. Tan and Helsten for opening up a discussion as well as introducing potential solutions to make intraoperative handovers safer.

We have several reasons to address this issue. First and foremost, as physicians, we must ensure that patient safety is never jeopardized by a lapse in communication. Second, anesthesiologists take care of patients who are typically sedated or unconscious and cannot advocate for themselves. Third, the 2006 Joint Commission patient safety goal requiring a standardized approach to handoff communication may specifically address intraoperative handovers down the road. Fourth, our surgical colleagues should feel confident that quality of care is not being compromised by breaks or shift changes.

Dr. Tan described a unique approach to the handover process at his institution. Although electronic charting is not present in all settings, it is still possible to develop handoff tools or checklists that are specific to our practice.

Nina Singh-Radcliff, M.D.
Atlanticare Regional Medical Center, Pomona, New Jersey