Content of Weblogs Written by Health Professionals

Abstract

Medical weblogs ("blogs") have emerged as a new connection between health professionals and the public.
To examine the scope and content of medical blogs and approximate how often blog authors commented about patients, violated patient privacy, or displayed a lack of professionalism.
We defined medical blogs as those that contain some medical content and were apparently written by physicians or nurses. We used the Google search term "medical blog" to begin a modified snowball sampling method to identify sites posting entries from 1/1/06 through 12/14/06. We reviewed five entries per blog, categorizing content and characteristics.
We identified 271 medical blogs. Over half (56.8%) of blog authors provided sufficient information in text or image to reveal their identities. Individual patients were described in 114 (42.1%) blogs. Patients were portrayed positively in 43 blogs (15.9%) and negatively in 48 blogs (17.7%). Of blogs that described interactions with individual patients, 45 (16.6%) included sufficient information for patients to identify their doctors or themselves. Three blogs showed recognizable photographic images of patients. Healthcare products were promoted, either by images or descriptions, in 31 (11.4%) blogs.
Blogs are a growing part of the public face of the health professions. They offer physicians and nurses the opportunity to share their narratives. They also risk revealing confidential information or, in their tone or content, risk reflecting poorly on the blog authors and their professions. The health professions should assume some responsibility for helping authors and readers negotiate these challenges.

Full text

Content of Weblogs Written by Health Professionals
Tara Lagu, MD, MPH
1,2
, Elinore J. Kaufman
1
, David A. Asch, MD
2,3
,
and Katrina Armstrong, MD, MSCE
1,2
1
Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania, Philadelphia, PA, USA;
2
Leonard Davis Institute of Health
Economics, University of Pennsylvania, Philadelphia, PA, USA;
3
Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs
Medical Center, Philadelphia, PA, USA.
BACKGROUND: Medical weblogs (“blogs”) have emerged
as a new connection between health professionals and
the public.
OBJECTIVE: To examine the scope and content of
medical blogs and approximate how often blog authors
commented about patients, violated patient privacy, or
displayed a lack of professionalism.
DESIGN: We defined medical blogs as those that contain
some medical content and were apparently written by
physicians or nurses. We used the Google search term
“medical blog”to begin a modified snowball sampling
method to identify sites posting entries from 1/1/06
through 12/14/06. We reviewed five entries per blog,
categorizing content and characteristics.
RESULTS: We identified 271 medical blogs. Over half
(56.8%) of blog authors provided sufficient information
in text or image to reveal their identities. Individual
patients were described in 114 (42.1%) blogs. Patients
were portrayed positively in 43 blogs (15.9%) and
negatively in 48 blogs (17.7%). Of blogs that described
interactions with individual patients, 45 (16.6%) in-
cluded sufficient information for patients to identify
their doctors or themselves. Three blogs showed recog-
nizable photographic images of patients. Healthcare
products were promoted, either by images or descrip-
tions, in 31 (11.4%) blogs.
CONCLUSIONS: Blogs are a growing part of the public
face of the health professions. They offer physicians and
nurses the opportunity to share their narratives. They
also risk revealing confidential information or, in their
tone or content, risk reflecting poorly on the blog
authors and their professions. The health professions
should assume some responsibility for helping authors
and readers negotiate these challenges.
KEY WORDS: weblog; professionalism; Internet.
J Gen Intern Med 23(10):1642–6
DOI: 10.1007/s11606-008-0726-6
© Society of General Internal Medicine 2008
INTRODUCTION
Weblogs, or blogs, are journal-style websites whose authors
post entries over time. In the last few years, blogs have
contributed to a large increase in publicly available informa-
tion and dialogue on topics from authors’personal lives to
global politics. Technorati, a Web-tracking service, recently
estimated that there are more than 70 million blogs, with an
average of 120,000 new blogs being created each day.
1
Although it is impossible to ascertain the number of these
blogs generated by health care providers, a substantial
medical blogging community exists.
2–8
Scholarly articles on medical blogs have focused solely on
the potential benefits of health information blogs.
2,3,9–14
Many
physician and nurse blog authors, however, report personal
experiences and clinical interactions. These blogs allow physi-
cians and nurses to share their narratives, knowledge and
experience with the healthcare world. Blogs can accurately
portray the challenges facing our professions. They are also
part of the public face of healthcare—health professionals who
share private thoughts in public settings risk revealing confi-
dential patient information or otherwise reflecting poorly on
the profession.
4,7,8,15–19
Thegoalofthisstudywastoevaluate
the scope and content of blogs written by health professionals.
Specifically, we aimed to 1) approximate the number and content
of blogs that described interactions with patients; 2) determine
how often blog content violated patient privacy or confidentiality;
3) evaluate whether blogs conformed to professional norms such
as the obligation to reveal conflicts of interest.
METHODS
We defined a medical blog as a web-based narrative containing
some medical content and written in first-person journal style.
We wanted to include the breadth of the medical blogging
community but needed to limit the selection process to blog
authors most likely to appear as medical professionals to the
public. Physicians and nurses represent the vast majority of
the professional medical blogging community, so we sampled
only blogs whose authors who could be identified as physi-
cians or nurses. We included all nurses, both those in a
traditional nursing role and those functioning as advanced
practitioners. We sampled blogs written by post-graduate
trainees (residents and fellows) but did not include blogs
written by students. Many blogs include simple biographical
author profiles, and the majority of authors identify their
profession in these sections. We also included eight blogs with
titles (but not profiles) indicating that the author was appar-
Received December 9, 2007
Revised May 22, 2008
Accepted June 26, 2008
Published online July 23, 2008
1642

ently a physician or nurse (e.g., Angry Doctor and Geek Nurse)
and ten blogs whose authors were identified as a physician or
nurse only in the text of blog entries.
We conducted a Google search using the term “medical
blog,”and found that among the first results were several
medical blog aggregators. Blog aggregators are websites that
display many blogs in a consolidated view on a single webpage.
Blogs are connected to the aggregator by links, website
addresses imbedded within the pages. Readers click on the
links and are directed to the listed blog. It is likely that lay
readers searching for medical blogs would find and use these
aggregators. Therefore, we examined all blogs listed on the first
three aggregators (Medlogs,Yahoo Health and Medicine Blogs
and The Medical Blog Network). From the blogs identified
initially, we expanded our search using a modified snowball
sampling method.
Snowball sampling follows a referral chain, meaning that
subjects who fit the selection criteria of a study provide
referrals to other people who also may fit the selection criteria.
This method has been shown to be effective in reaching hidden
populations.
20
In our modified method, we identified blogs
linked to our original sample of aggregated blogs. This revealed
another group of previously unlisted blogs which were also
included in our sample if other criteria were met. Duplicates
were eliminated from the sample; the mean number of
eliminations due to duplication was 3.2. Our final sample
was comprised of all medical blogs within one link of the three
blog aggregators. To determine the effectiveness of our sam-
pling method, we searched for individual medical blogs using
the Google search terms “medical blog,”“physician blog,”
“doctor blog,”and “nurse blog”and did not uncover any new
blogs. Additionally, we conducted a search of recent items in
the lay press that featured individual medical blogs
4–7
and
again found no new blogs. To assess whether we reached blogs
with significant readership, we reviewed “hit counters”for
some included blogs and found that these blogs received very
frequent visits. Fat Doctor, for example, received over 200,000
visits in the previous year.
We used the blog as the unit of analysis. Each blog has
multiple narrative entries, usually on different dates, similar to a
journal. A single entry may not adequately represent a blog’s
content. However, frequency of updating varies greatly between
blogs. Some authors post items daily while others post less than
once per month. To extract enough entries to obtain a rough
approximation of a given blog’s content, while avoiding over-
sampling any individual blog, we fixed the number of entries we
read at five per blog. Blogs, by their nature, address current
topics, so we limited our inquiry to entries dated between
January 1, 2006 and our index date of December 14, 2006. For
the seven blogs that did not have five entries in this time period,
we included all entries in 2006 before the index date.
We aimed to approximate the frequency of patient com-
ments, privacy violations, and other unprofessional content.
Instead of content analysis software, we used a previously
described method of qualitative analysis.
21
Two reviewers, a
physician and a trained research assistant, read half of
sampled blogs in small batches of 10–20. With each batch,
the reviewers discussed characteristics of each blog and their
common themes. Any disagreements were resolved by consen-
sus. The reviewers discussed difficult decisions with a third,
independent physician reviewer until consensus was achieved.
This process produced a list of themes common to many blogs.
From these themes, we defined 16 potential characteristics of
blogs and a method for coding these characteristics. The two
primary reviewers then independently reviewed and coded all
remaining blogs. All disagreements were resolved by consen-
sus to achieve the final ratings. We measured reviewer
agreement on all characteristics with the kappa statistic. All
variables were also examined with the use of descriptive
statistics.
RESULTS
We identified 1,434 blogs within one link of the blog aggrega-
tors. Of these, 279 were written by a doctor or a nurse in a
journal style and had at least one entry in 2006. Eight of these
blogs had no health-related content and were therefore
excluded from the sample. Our analysis includes the remain-
ing 271 blogs.
We identified 16 descriptive characteristics of these blogs.
Reviewer coding for four of these characteristics showed very
little variation (with five or fewer differing responses). For 11 of
the 16 characteristics, kappa statistic was ≥0.6. Blog content
was similar for physicians and nurses. Table 1provides a
systematic overview of our results, and in this section we have
excerpted representative examples of each characteristic. All
referenced weblog addresses (URLs) are included in Table 2,
unless otherwise indicated.
BLOGGER AUTHOR IDENTIFICATION
Over half of the 271 blogs had identifiable authors; 89 (32.8%)
authors provided both first and last name and 43 (15.9%) gave
enough information about their name, subspecialty, or loca-
Table 1. Blog Characteristics
Blogs
n (%)
Reviewer
agreement
kappa
Blog author identification
First name 139 (51.3) 0.8
Last name 95 (35.1) 0.9
Location 117 (43.2) 0.7
Identifiable photo 60 (22.1) 0.6
Sub-specialty 197 (72.7) 0.6
Patient privacy
Patient images 3 (1.1) 0.6
Patient radiographs 8 (3.0) 0.7
Patient laboratory studies 0 (0.0) *
Other privacy information 1 (0.4) *
Patient depictions
Any comments about patients 114 (42.1) 0.8
Negative comments about patients 48 (17.7) 0.7
Positive comments about patients 43 (15.9) 0.5
Commentary on health profession/heath
care system
Comments about the health care system 137 (50.6) 0.5
Positive comments about health
care profession
108 (39.9) 0.4
Negative comments about health
care profession
86 (31.7) 0.6
Product endorsement
Blog posts promote health care products 31 (11.4) 0.6
1643Lagu et al.: Medical WeblogsJGIM

tion to be identifiable. A recognizable photo was displayed by
22% of authors. Of sampled blogs, 206 (76.0%) were written by
physicians, including 23 interns and residents, and 59 had
nurse authors (21.8%). The remaining six blogs (1.8%) were
written by groups of health professionals including both
doctors and nurses.
PATIENT PRIVACY
Forty-five blogs (16.6%) that described interactions with
individual patients also included significant identifying infor-
mation about the blog author. Three blogs showed recogniz-
able photographic images of patients, and one provided an
extensive description and links to pictures of a patient. Eight
blogs showed patient radiographs without further identifiable
information.
PATIENT DEPICTIONS
Eighteen (6.6%) blogs contained both positive and negative
patient content. Forty-three blogs (15.9%) described patients
in a positive light, often praising patients’good spirits,
manners, or stoicism. All quotes are taken directly from the
blog sites.
“Anyway, we both enjoyed exploring this issue together. I
know she never really talked about it with someone who
got it so quickly and easily. It was one of those sessions
that I felt was really authentic on both our parts and
made me happy all day.”abortionclinicdays
“One of my patients last night was a pastor, who was
such a trooper. i mean the guy didn’t even complain
when we had to transfer him to a different unit at 4 A.M.”
About a Nurse
“In particular, caring for visible wounds on the feet can
have meaning, I think. In this case, it was about
acknowledging the losses and suffering inherent in his
journey, and readying him to travel again. Over and over,
I am honored to wash my patients’feet.”Talking RN
“She nearly died a few times, from sepsis, from organ
failure, from that bleeding episode. But somehow she
made it. Somewhere I have a beautiful hand-embroi-
dered silk tablecloth she sent me when she returned
home.”blog name withheld to maintain patient privacy
Forty-eight blogs (17.7%) described patients in a negative
light, including several comments that were more insulting
than the ones quoted below.
“The unwritten definition of proper patient: attached to a
breathing machine, a lot of wires and completely sedated
or even paralyzed.”Adrenalin Rush
“She was a stupid, lazy, selfish woman all of which
characteristics are personal problems, not medical
issues or barriers to care”Panda Bear MD
“When you come into the ER yelling, moaning, and
twisting in agony because you have a sprained ankle - I
will hate you. Why will I hate you? I will hate you
because the man in the next stretcher is dying of an
excruciatingly painful form of cancer, yet he is silent.”
ER RN
“I once looked after a patient who has Googled every
ache and pains she ever had, every pills or tablets taken
and every diagnoses accumulated as if it is some form of
a“fascinating morbid collection”, literally and figurative-
ly. Makes you wonder: What’s wrong with collecting
stamps? Or stuffed dead animals? How could anyone
obsessively collect an alphabetically arranged mental
card index of a random number of pathologies or
allergies that they could just pull out from the back of
their heads each time they see a slight rash or a spot of
discoloration on their skin?”MDOD
COMMENTARY ON THE MEDICAL PROFESSION
AND THE HEALTH CARE SYSTEM
About half of sampled blogs (50.6%) discussed some aspect of
the health care system. Topics ranged from insurance and
malpractice to end-of-life decision making and the doctor-
patient relationship.
“I often rant on the importance of taking enough time
during a patient interview, exam and visit. As long as our
current payment system encourages physicians to in-
crease volume, time spent per patient will suffer. We
should avoid rushing in medicine. We need time to
think, contemplate and observe...Perhaps speed kills,
at least indirectly.”DB’s Medical Rants
Forty percent of blogs commented positively about health
professions. These comments often reflect on the rewarding
aspects of blog authors’own jobs or spoke highly of colleagues.
“Also, kudos to Dr W, who was the most direct that I’ve
heard any doctor be with family on our unit. ‘Your wife is
going to die. If we allow things to continue as they are
Table 2. Blog URLs*
Blog title Web address
Medlogs http://www.medlogs.com
Yahoo Health and Medicine
Blogs
http://dir.yahoo.com/health/
news_and_media/blogs
The Medical Blog Network http://www.trusted.md
Angry Doctor http://angrydr.blogspot.com/
Geek Nurse http://geeknurse.blogspot.com/
Fat Doctor http://fatdoctor.blogspot.com/
Abortionclinicdays http://abortionclinicdays.blogs.com/
About a Nurse http://www.aboutanurse.com
talking RN http://talkingrn.blogspot.com/
Adrenalin Rush http://howling-adrenalin-rush.
blogspot.com/
Panda Bear MD http://www.pandabearmd.com
ER RN http://errn.blogspot.com/
M.D.O.D http://docsontheweb.blogspot.com/
DB’s Medical Rants http://www.medrants.com/
Coffee & Conversation in
a smoky room
http://jodaya.blogspot.com/
Medicine and Man http://medicineandman.com/
*Accessible as of May 21, 2008
1644 Lagu et al.: Medical Weblogs JGIM

now, she will die within the week...Her disease has
already made that decision for her. But you have the
decision to make about how she will die.’Sounds harsh,
but he somehow conveyed the utmost compassion,
empathy, and wisdom in that statement.”blog name
withheld to maintain patient privacy
Approximately 30% of blogs included negative comments
about aspects of the health profession. These comments
included complaints about particular colleagues, the medical
hierarchy and rules:
“We have one unit in the hospital where we always float.
Why? Because they have terrible management, they are
extremely disorganized, there is no teamwork so it’s
every man for himself, the staff is rude and lazy, and
because of all these things they can’t keep staffed for
very long so we have to go fill in.... on the hardest
patients on the floor.......the ones nobody wants. That
way the rest of the nurses can sit at the station and flip
through magazines all day. If I asked for help I got
attitude.”Coffee & Conversation in a smoky room
PRODUCT ENDORSEMENT
Thirty-one blogs (11.4%) explicitly promoted a specific health-
care product, providing product images, descriptions, or
advocacy. None of these blogs provided information on conflict
of interest.
“Up until now the treatment of this condition involved
free water restriction and removal of inciting factors.
Now a new drug —[name deleted]—promises to change
it all.”Medicine and Man
DISCUSSION
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 broad-
casts. 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,medicalblogsarepartofthepublicfaceof
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 deco-
rum. 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 rela-
tionship 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 anony-
mous 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 be-
cause 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 advertise-
ments 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 sub-
stantial, 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 pa-
tient 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
1645Lagu et al.: Medical WeblogsJGIM

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 representa-
tion 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 re-
solved 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 interpre-
tation 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 unpro-
fessional content and tone, privacy violations, and hidden promo-
tions 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 organiza-
tions 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.
Acknowledgements: Funding: Supported in part by The Robert
Wood Johnson Foundation Clinical Scholars Program.
Conflict of Interest: None disclosed.
Corresponding Author: Tara Lagu, MD, MPH; Robert Wood
Johnson Clinical Scholars Program, University of Pennsylvania,
423 Guardian Drive, 13th Floor Blockley, Philadelphia, PA 19104,
USA (e-mail: lagutc@gmail.com).
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