Making the Virtual Rounds: The Use of Blogs by Health-Care Professionals

Grand Rounds—The Best of the Medical Blogosphere

Grand Rounds (http://getbetterhealth.com/grand-rounds), founded in September 2004, was a network of health-care bloggers (also called med-bloggers) that shared a weekly summary of notable contributions made to the medical blogosphere. This digital compilation is an example of what is referred to as a blog carnival (Morrison, 2013). Blog carnivals are weekly online discussions among bloggers with similar interests. It is a type of online community of practice in which bloggers join together to share information on a regular basis. With Grand Rounds, the topics of the blog summaries varied from week to week with a chosen blogger, or blogger group, taking responsibility for compiling content from the Internet. The topics included: doctor–patient encounters; a profile of a particular person involved in medicine; experiences in medical education; commentary on a new scientific discovery; and, theorizing and debating various aspects of health-care delivery. The last compilation of Grand Rounds was posted on March 13, 2012 shortly before going on an indefinite hiatus. In total, there were roughly 200 weekly carnivals among members of the Grand Rounds.

The data for this article are gathered from a series of interviews with medical bloggers (n=83) that were conducted by the network itself and posted on Grand Rounds between November 17, 2005 and July 24, 2007. Those who were interviewed tended to be well-known and highly active medical bloggers—such as “Kevin, MD” and “Medpundit”—whose blogs have been profiled in other studies (e.g., Cohen, 2007). Interviews asked bloggers to discuss what was unique about their own blog, the reasons why they started to blog, and the significance of this practice for this work. Hence, the focus is more about motivations for blogging and less about particular medical or health-related topics. In treating these interviews as data, we were able to extract important insights not simply about what HCPs blog about but more specifically why they blog.

While dated, analyzing this sample of interviews is still relevant for a number of reasons. Namely, there is little qualitative research that explores the purposes for which physicians use the Internet (Hughes et al., 2009) and, to our knowledge, there have been no studies that take the Grand Rounds forum as a dataset. Furthermore, scholars have demonstrated that blogging remains popular among HCPs over the past 10 years. For instance, the physicians in Panahi et al.'s (2016) recent study expressed that blogs were their second most preferred online platform after Twitter (p. 102). Also, in their extensive review of 951 health-related blogs found online, Miller and Pope (2010) note that 49.8% of the bloggers worked in health professions (p. 1515). Since blogs continue to be used frequently by HCPs, we believe that the rich data found in the Grand Rounds interviews warrants examination and can be used toward gaining a better understanding of the reasons for medical blogging.

Methods

Since we did not perform these interviews ourselves, we are conducting a “secondary data analysis,” which is the practice of reusing qualitative data that was independently collected by others (Glaser, 1962; Heaton, 2008). While secondary analysis often refers to using data from other scholarly research, it can also be performed on other types of accessible data—like online interviews. In the methodological literature, there are particular recommendations about how and when to use a secondary analysis. Of chief importance is assessing the comparability of past and current research. Explained by Glaser (1962), “If the data are comparable with respect to population, situation, and variables, then the social scientist merely analyses it according to the specific operating problem” (p. 72). We believe that because of an equivalent focus on asking HCPs about the reasons why they blog, the interview data from Ground Rounds can be effectively analyzed to answer our research question. Since these interviews were not borne out of academic research, we treat them comparably to online documentary data. We are more concerned with examining the narrative accounts as provided by the respondents than the questions they were asked.

We take a “constant comparative” approach to data collection and coding (Johnson, 2000). We use this technique because it is particularly well suited to interpreting personal narratives or interviews, as demonstrated by other qualitative studies of physicians' Internet use (e.g., Hughes et al., 2009; Walden, 2013). We began by performing some preliminary online searches and found Grand Rounds to be a hub for medical bloggers. Digging deeper into the forum, we discovered that they conducted interviews with their members. Because of the striking relevance to our research question, we took these interviews as a purposive sample to analyze. Upon archiving and organizing the data, we began coding the interviews using an open and inductive method. Simple keywords (e.g., “privacy,” “patient interaction,” “information-seeking,” etc.) were first used to label the content of bloggers' responses. After reviewing and comparing the frequency of these initial codes, we then developed a final set of more detailed categories that described patterns from across the interviews.

Once the interviews were coded, we were able to perform a qualitative thematic analysis. Simply put, a qualitative thematic analysis is “a method for identifying, analysing and reporting patterns (themes) within data. It minimally organizes and describes your data set in (rich) detail” (Braun & Clarke, 2006, p. 79). This type of analysis places less emphasis on the quantification and generalizability of findings and is more appropriate for the development of thick analytical descriptions. Performing the analysis allowed us to refine and replace our original codes and focus even more narrowly on the reasons for blogging and the “functions” of blogs for physicians (Walden, 2013, p. 241). In so doing, we were able to determine the most prevalent themes in interview content with respect to our research question about how and why HCPs use blogs. We derived five overall themes that help explain how these HCPs account for blogging. By drawing on a number of reflections and opinions, we provide some valuable insight into the intentions of medical bloggers and their relationship to the health-care system.

(Re)establishing Reputation

As mentioned earlier, once private and institutionalized medical information is now widely available online and this newfound accessibility may be encouraging a “deprofessionalization” of health professionals. Some patients no longer rely on, or uncritically accept, the advice given to them by doctors and choose to explore second opinions on the web. Because a large number of HCPs are wary about misinformation on websites, they go online to expose contradictions, critique “bad science,” or defend certain therapy and product recommendations. These practices may be answering calls from various medical organizations, such as “ASCO,” who urge physicians to “take advantage of the greatest opportunity to disseminate credible information and influence both our peers and our patients” (Lewis & Dicker, 2015, p. 768). Med-bloggers frequently explain that they started writing blog posts because most people without medical degrees are simply unable to properly interpret and understand health writing. Expressed by Dr. Emily De Voto (The Antidote), “It really does take a certain amount of critical understanding of science to separate the wheat from the chaff, not to mention putting findings in context.” Therefore, HCPs use their blogs to inform readers about what is credible and, in effect, reinforce their authority as medical experts.

A number of bloggers also express a desire to personally assist patients in navigating the potentially overwhelming and confusing information about health care. For example, Graham Walker (Over My Med Body) states: “How many people are probably going to see the Medicare Part D Walkthru? Not many. But I keep doing it, hoping that it maybe helps a few people make sense of it.” These types of blogs can perhaps improve relationships between doctors and patients. As Fard Johnmar (Envision Solutions) states, “because of the information available on the Internet, patients are entering into partnerships with their physicians where they are playing a larger role in the their care.” However, these actions also constitute an attempt at re-professionalization; they reestablish HCPs as the necessary intermediaries of medical and lay knowledge. On this topic, Dr. Jon Mikel Iñarritu (Unbounded Medicine) explains:

The issue is whether the information is right or useful, and whether you know how to apply that information. There's a solution to this problem: have professionals write about their field, and explain it in plain language – not a specialized blog, but one “readable” to anyone. (Dr. Jon Mikel Iñarritu, Unbounded Medicine)

Interacting Informally With Patients

The ability to engage in new forms of interaction across space and time is perhaps the most obvious opportunity that the Internet affords. While web tools, like blogs, are not replacing face-to-face encounters, they do have the potential to enhance doctor–patient communication (Cohen, 2007). By providing a space to interact casually and share personal writing, online media can improve doctor–patient relationships by “humanizing” the physician (Alpert & Womble, 2016, p. 830). In other words, this practice of entering into trusting and open conversations “increases the human sensibilities of both patient and doctor and heightens the quality of their interaction” (Mechanic, 1998, p. 286). In this context, HCPs can use their blogs to communicate informally with patients, which in turn provides readers with a richer and more intimate understanding of their physician's identity and personality.

How this new doctor–patient relationship is navigated varies by blogger. Some, like Dr. Charles (The Examining Room of Dr. Charles), explain how their patients have reacted to their blogs: “I've learned that my readers – the patients – can be quite amazed and indeed frightened that there is a regular, opinionated, and sometimes judgmental person behind each white coat.” Others express worry over being discovered by patients. In reference to the use of a pseudonym, “MedPundit” says, “[it's] because I don't want a knowledge of my personal beliefs to be an inhibiting factor in my patient relationships.” By contrast, several bloggers openly mention their blog to patients and believe that they have experienced professional gains from online interaction:

Some of my patients are aware of it, and we discuss it during patient visits. Some patients have even found me via the blog and switched to me as their primary care physician. There seems to be a demand for physicians who understand the Internet's role in patient health information today. (Dr. Kevin Pho)

Blogging as Therapeutic

In popular culture and much social research, clinicians are often portrayed as objective and stoic despite the many emotional aspects of their work (Nettleton, Burrows, & Watt, 2008). To address or alleviate some of these conflicting expectations and emotions, HCPs may turn to blogging. Life writing can indeed improve the mental and physical health of physicians by providing emotional equilibrium, self-healing, and reducing social isolation (Shapiro, Kasman, & Shafer, 2006). These benefits of blogging are referenced in many ways by the HCPs in this sample. For example, Dr. Allen Roberts (GruntDoc) says that he started his blog as a way to “blow off some steam” and Dr. John Crippen (NHS Blog Doctor) describes his blogging experience as “enormously therapeutic.” Similarly, “PaedsRN” uses his blog, in part, to communicate “the kinds of mixed-up feelings” that medical workers have. Others even claim that writing about your feelings is not only personally cathartic, but it can also help raise awareness of mental health issues. As Dr. Deborah Serani explains, “I am open about my own experiences with depression, and I think bringing that personal piece to my blog lets others see that they don't have to be ashamed.” Blogging is therefore considered to be a constructive way to express and promote the expression of a range of emotions.

Many bloggers note that “venting” or “cathartic” posts are written during or following an upsetting event in the workplace, such as an interpersonal conflict or a loss of a patient. Typically, doctors fear that emotional responses to patients will be seen as unprofessional in public medical contexts (Nettleton et al., 2008) and this expectation can become a source of private anxiety:

Often I have to suppress my emotions in the course of my work and I find this one of the more difficult and unhealthy things that I do … Surgeons aren't meant to sit in a treatment room cuddling a tiny baby with tears in their eyes … They're meant to be made of steel. Or at least, that's what we're encouraged to believe. (“Barbados Butterfly”)

Such suppression seems unreasonable given the extremely challenging nature of many health care professions. Blogging is said to provide some much needed solace under times of occupational duress: “I think every healthcare worker feels the enormity of their task and the impossibility of perfection. We need to have an outlet, some cathartic ‘generativity’ that helps us remember why we enlisted in this often heartbreaking field to begin with, or at least allows us to poke fun at ourselves” (Dr. Charles, The Examining Room of Dr. Charles). Hence, for many HCPs, blogs serve a therapeutic function in their lives; they read and write them as a way to find personal and interpersonal comfort amidst various forms of stress and pressure.

Describing and Negotiating Constraints

It is necessary to recognize that health-care blogs are particularly constrained by ethical and institutional obligations. It is common knowledge that doctors are held to a strict responsibility to not divulge intimate or identifying information about patients. In a number of cases, the online personal writing of med-bloggers becomes subject to organizational regulations or screening. These bloggers must negotiate telling their story and telling the “right” story. In this sense, writing is not an unrestricted process; it must align with particular social and institutional expectations. When HCPs talk about why they blog, many describe not just the benefits but also the challenges of using social media.

It is not surprising then that many med-bloggers adopt pseudonyms. “MedPundit” admits, “I didn't want to embarrass my employer with my views.” Anonymity is often a means to maintain candor and ensure protection, especially if writing vitriolic pieces about their job. Regardless of any disclaimers to the contrary, med-bloggers feel that they inevitably represent their employers, and express trepidation at the thought of readers conflating their opinions with that of the company they work for. Ethics are also heavily considered when writing posts about patients. Anonymity does not exempt HCPs from ethical standards of their workplace, resulting in a tension between autonomy and morality:

I exhaustively reviewed ethical standards for what doctors are “allowed” to say, and feel that all medical bloggers should be careful and follow the implied rules. But to let lawsuit fear creep into the realm of reasonable self-expression is to have lost the last vestige of freedom. Doctors are still brave enough to deliver babies, to do their best to find cancer early, to remove ruptured appendixes despite the fact that we all get sued eventually, probably multiple times in our careers. We must certainly be brave enough to have a public voice, whether in the form of letters written to the editor about our deranged healthcare system, or as semi-obscure words describing the hour of a fictionalized patient's death as shared on medical blogs. (Dr. Charles, The Examining Room of Dr. Charles)

Sometimes, however, medical organizations are supportive of blogs and recognize their utility. Upon discussing her blog with her clinical director, “Tundra PA's” writing was incorporated into the company's recruitment website because they felt it accurately reflected their work life. In other cases, employers become aware of blogs independently:

The people in charge of my program know about my blog; about 10 months ago they spoke with me about it and asked that I make sure that I am meticulous about privacy issues. The fact that they knew about the blog and that the head of the program had read it was a little disconcerting, even though I've never said one word about the program. Just knowing that you're being watched is enough to make you think twice before you write something that refers to a real patient. (Dr. Sam Blackman, Blog, MD)

Promoting Community and Reform

By engaging in regular online communication, bloggers can create strong bonds with one another. Many acknowledge that through writing, commenting, and collaborating, they are part of a “virtual community” (for a review of definitions, see Fuchs, 2006). Members of other blogging groups—such as “mommy bloggers”—have described how feelings of support and solidarity can stem from being involved in such a community (Lopez, 2009; Morrison, 2011). It is common for med-bloggers to write about the trends, trajectory, and relative well-being of their online group. Because personal blogs often incite self-disclosure and statements of empathy, the blogosphere can provide compassion and communality not found elsewhere on the Internet.

There is a general sentiment that the development of an influential online community can be an asset in prompting medical reform. However, a major debate surrounds the question of what type of medical blogging is useful. With the various styles, themes, and genres within the group, there are contentions that some kinds of blogging are more beneficial than others. One clear division is between what we call “daily” blogging and “medical issues” blogging. “Daily” bloggers—like “KeaGirl”—use a blog to “chronicle [their] day-to-day events.” They emphasize the value in doctors shedding light on their own interpretations of work experiences. Their position is summarized well by Niels Olsen (The Haversian Canal) in stating: “we, the millions of little reporters, by looking a little closer to home and reporting our observations, can add enormous value to the Internet one little bit at a time.” These writers believe that giving readers access to the context and untold meanings associated with even the most mundane tasks is an important endeavor. Everyday posts are considered a way to demystify health care for patients and promote supportive interaction among practitioners.

On the other hand, the “medical issues” bloggers are concerned primarily with politics, policies, and social change. They typically regard such casual and observational blogging as trivial. These individuals express that med-bloggers should be more concerned with increasing their quantity of readers and developing a collective identity in order to effectively provoke change at an institutional level. Dr. Chris Rangel, for instance, is described as using his blog to “agitate for reform”:

The other thing I'd like to see is for a medical blog to make that quantum transition from entertainment source to advocate…In the end, physicians, healthcare workers, patients, and healthcare access and quality will all be on the losing end of these decisions unless we act now to become a major player in the game.