Patient-Targeted Googling and Psychiatry: A Brief Review and Recommendations in Practice
Publication: American Journal of Psychiatry Residents' Journal
The ever-increasing utilization of social media services by both the public at large (1) and clinicians and trainees (2–4) has changed how physicians make use of information posted online. One consequence of this trend is the advent of patient-targeted googling (PTG), an information gathering technique used by members of a health care team to search for information about a patient online. Limited data on the prevalence of PTG use among mental health professionals suggest that it is common and often includes inappropriate searching for patient information (5). Case reports have demonstrated beneficial uses of PTG (6)—including, for example, using social media to contact a patient lost to follow-up after a previously discovered genetic mutation was found to be clinically significant (7)—and multiple studies have revealed the utility of social media in identifying patients at increased suicide risk (8–9). Despite some promising applications, PTG is a technique rife with ethical concerns deserving of the psychiatrist’s attention prior to engaging in a search for patient information. The present article will review published guidelines on the use of PTG and make practical recommendations for psychiatrists who are considering this technique in the care of their patients.
A Framework for Incorporating PTG Into Practice
Few formal guidelines have been published concerning the use of PTG in the clinical setting. A position paper discussing the use of the Internet by physicians briefly mentions PTG but makes no specific recommendations for incorporating the technique into practice (10). A more thorough discussion of PTG in the context of psychiatry, by Clinton et al. (11), reviews potential issues related to its use, including the exploitation of patients based on discovered information, violations of patient privacy, subjugation of a patient’s interests to the curiosity of the psychiatrist, and harm to the psychotherapeutic relationship. The relative ease and anonymity afforded by online searching may promote regular, casual searching of information about patients and heightens these concerns. The authors recommend that the decision to utilize PTG should be determined on a patient-by-patient basis and always in service “to the patient’s best interests” and offer a series of questions for the psychiatrist to ask him- or herself as guidance for performing ethically permissible searches.
Due to these concerns, review of the ethical issues surrounding PTG, particularly for younger clinicians who are more likely to utilize the Internet in the course of clinical care, is warranted. The following guidelines are based on the framework developed by Clinton et al. (11) and will similarly emphasize concrete, practical considerations over abstract ethical constructs.
Framing a Search
The rationale behind a search, the specific information being sought, and how that information will assist in the patient’s treatment must be identified prior to a search. PTG performed out of simple curiosity or that is unlikely to contribute positively to a patient’s treatment has no clinical utility and may be quite harmful (11). Patients may perceive accessing publicly posted information in the context of a treatment relationship as an invasion of privacy and violation of trust (12). The breadth of information available online is potentially more invasive than traditional violations of clinical boundaries—for example, visiting a patient’s home or place of work—and the ease of finding personal information online may provide a false sense of acceptability to psychiatrists. Because of these concerns, PTG may be most appropriate as a tool of last resort, utilized only if other routes of information gathering have failed.
The consequences of discovering unexpected information in the course of a search and its impact on the treatment relationship is also worth considering. A case report involving a nurse’s impromptu use of PTG to find information about a mother whose behavior toward her child raised concerns highlights the difficulties of managing unexpected information (13). When weighing the risks and benefits of conducting a search, attentiveness to the potential impact of all discovered information is suggested.
Obtaining Informed Consent
It is recommended that informed consent be obtained prior to beginning PTG (14). Patients should be made aware of the purpose and risks of a search, including the potential discovery of unrelated personal information and documentation of search results in the patient’s medical record (11). By obtaining informed consent, the psychiatrist maintains honesty in the therapeutic relationship, informs the patient of both the risks and benefits of a search, and welcomes the patient to provide the sought information on his or her own terms before relying on PTG. In some cases, a patient may refuse to consent to a search; the decision to continue a search in this setting warrants careful consideration due to the potentially negative impact on the treatment relationship if the search is later disclosed to the patient.
Completing a Search and Assessing Obtained Information
No standard protocols for performing PTG have been published. Lane et al. (6) briefly discuss some of the tools available for performing PTG, including public record databases, as well as innumerable resources accessible via search engines. Additionally, McNary (15) recommends using search terms that limit the potential of discovering information unrelated to the focus of the search.
Some commentators have argued that the uncertainty surrounding the accuracy of information obtained online requires caution (16) or even precludes the use of PTG in clinical care (13). Concerns raised about information obtained online include the interpretation of online lingo and differences in an individual’s online and real-world persona, which may weaken the reliability of PTG (17). Attempts to verify discovered information prior to use in decision making are paramount but may not be possible. Using information obtained from third parties (e.g., social media posts) especially requires caution. Simple misidentification, particularly in cases using common names, can also occur. Because of these concerns, verification of discovered information with the patient or additional collateral is recommended.
Documenting and Disclosing Discovered Information
At the conclusion of the search, any information used in clinical decision making should be documented in the patient’s medical record (15). Consistent documentation of the results of all PTG can assist in avoiding casual searches and ensure that the medical record reflects a clear rationale for treatment decisions.
The decision to disclose the results of PTG to the patient is more controversial. Clinton et al. (11) state that the decision to disclose information should be made on an individual basis. In the author’s opinion, information that guides management decisions should be disclosed to the patient with few exceptions. Direct disclosure of obtained information also allows the patient to correct inaccuracies, informing the psychiatrist’s judgment regarding the reliability of the information. Withholding information from patients may undermine the inherent trust of the treatment relationship and introduce a degree of secrecy that is unlikely to be therapeutically productive. The necessity of a search requires consideration if the disclosure of identified information to the patient may be problematic.
Should unexpected information relevant to ongoing treatment be discovered—for example, evidence of active substance use or acute suicidality or homicidality—direct discussion of concerning findings with the patient is recommended. Information suggestive of acute danger should not be ignored; in addition to an ethical duty to act, the psychiatrist may be exposed to medicolegal liability for ignoring evidence of acute danger (15). Discovered information that is not clinically significant need not be disclosed, though may shape a psychiatrist’s impression and treatment of the patient with therapeutic consequences (11).
Reassessment of Continued Searches
Repeated searches on a single patient warrant self-monitoring of the psychiatrist’s motivations for continued PTG in order to avoid ethically dubious searches (11). Consultation with an ethics service for an opinion on the necessity and appropriateness of repeated PTG can help avoid searches that may not be therapeutically beneficial.
Conclusions
PTG can be an indispensable and valuable tool for the psychiatrist in carefully chosen situations (see Table 1). While the process of PTG is itself straightforward, the consequences of its use are less clear and difficult to predict. Using a risk-benefit framework to determine the necessity and impact of a search, as well as acknowledging the invasive nature of PTG and its potential impact on the treatment relationship, is recommended. Discussion with a colleague, superior, or an ethics service prior to initiating a search with the goal of clarifying the benefits and appropriateness of PTG can be useful in difficult cases.
| Appropriate Usea | Inappropriate Use |
|---|---|
| Identifying a patient who is unwilling or unable to identify themselves | Physician curiosity |
| Acquisition of information critical to medical decision making | – Verifying clinically irrelevant aspects of a patient’s history |
| – Attempting to identify and contact a patient’s family members if necessary for disposition planning | – Searching for personal information irrelevant to a patient’s care |
| Searching for information necessary to contact a patient’s collateral if the patient cannot provide contact information | Searching for information that may be relevant, but not necessary, to providing clinical care |
| Contacting patients lost to follow-up in clinically urgent scenarios | – Searching a patient’s social media profile(s) for evidence of substance use |
| – Informing patients of abnormal test results that require further evaluation and treatment | – Using social media to verify aspects of a patient’s social history |
| Attempting to contact a patient when clear evidence of crisis is present | First-line use without initially attempting more focused information-gathering techniques |
| Routine searching for information on all patients regardless of clinical circumstances or urgency |
a
These scenarios assume that other attempts at obtaining the requested information—for example, from the patient directly or from designated collateral—have failed.
Moving forward, mental health professionals would benefit from definitive guidelines outlining the ethical use of PTG and similar techniques in routine clinical practice. Guidelines specific to psychiatrists taking into account the sensitive nature of psychiatric illness, the centrality of the relationship between psychiatrist and patient, and the effects of PTG on these aspects of care would be particularly beneficial. Education for younger clinicians—the population most likely to engage in PTG and its problematic use—focused on the responsible use of online information gathering has already begun (18). Before formal guidelines are developed, however, psychiatrists must take care to ensure that online searches for patient information are ethically permissible, are in service to a patient’s care, and include prudent assessment of the risks of the practice.
Key Points/Clinical Pearls
•
Patient-targeted googling (PTG) is an information-gathering technique that utilizes various online search engines to find information about a specific patient to aid in clinical decision making.
•
Though PTG can be immensely useful as a clinical tool, it is associated with significant risks and ethical concerns, including the violation of patient privacy and harm to the psychotherapeutic relationship; as a result, casual searches for patient information should be avoided and the technique used only if clinically necessary
•
PTG should be performed only after careful consideration of the risks and benefits before searching for information, a process that should include obtaining consent from the patient directly in most cases.
•
Information from PTG that is used in clinical decision making should be documented in a patient’s medical record and, with few exceptions, disclosed to the patient at the conclusion of a search.
Acknowledgments
Dr. Cole thanks Dr. Jennifer Huang Harris for her assistance.
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Published in print: May 01, 2016
Published online: 1 May 2017
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