Online Searches and Professionalism

This article is the fourth in a series designed to facilitate adaptation to modern digital media by helping psychiatrists maintain professionalism and boundaries when venturing into these new social territories. Specifically, this article addresses ethical concerns when using online search engines such as Google or Bing to gather information about patients.

Use of the search engine is a ubiquitous part of modern life. It is commonplace and acceptable for prospective patients to use online searches to identify and vet new doctors. It is commonplace but sometimes disconcerting to discover to what extent patients may have researched their psychiatrist online. Sometimes the searches go far beyond a provider’s website, publications, and online ratings and may include information about charitable contributions, family members, and property values. Such searches may feel intrusive, and the motivations behind extensive searches may be excellent fodder for therapy, but they are to be expected. A psychiatrist does well to employ sanguine curiosity in response to such activity by patients.

Sanguine curiosity is not the appropriate attitude when the tables are turned. There are certain situations in which Googling a patient may provide essential medical information, but at other times conducting an online search about a patient may be an inappropriate boundary crossing. An online search that is conducted to obtain specific medically necessary information that a patient or family is unable to provide—such as when a psychotic, delirious, or unconscious patient is seen in an emergency department or upon admission to an inpatient psychiatric unit—may yield important information about substance use, medical conditions, recent travel-related exposures, or contact information for family members. In this context, the intrusion into a patient’s privacy is offset by an urgent need to gather relevant information to guide necessary treatment.

Another acceptable scenario for Googling a patient is when the patient gives consent and when the online viewing is specifically related to the goals of treatment. For example, adolescents who are receiving unwanted posts to their Facebook page may agree to allow the therapist to view their online profile and offer feedback about any content that naively attracts aversive activity. It would be best to view the profile while the adolescent is in the office, so the patient knows exactly what the provider has seen (and to avoid the need for the provider to become a Facebook friend with the patient).

To conduct an online search when there is not a compelling, urgent need to do so or without specific consent violates a patient’s privacy and autonomy. A psychiatrist owes a fiduciary duty to each patient. This means that the psychiatrist places the patient’s interests above the psychiatrist’s interests and is primarily motivated in his or her professional interactions to meet the treatment needs of the patient. The psychiatrist may be curious about a patient’s residence, professional activities, media presence, or artistic accomplishments, but to gratify such curiosity without the patient’s knowledge crosses a boundary and violates the fiduciary nature of the treatment relationship. A patient might feel violated or betrayed if they learned of the online search.

Such a search may create new dilemmas for the psychiatrist. What if the psychiatrist learns an important detail about the patient’s personal or legal background that the patient has chosen not to disclose? Honesty and transparency might compel the psychiatrist to reveal what was learned in the search, but this may harm the patient’s ability to trust the psychiatrist and could damage or destroy the treatment alliance. Conversely, the psychiatrist may choose to remain silent about the online search but then struggle with authenticity in subsequent interactions with the patient. This is especially true if the patient eventually reveals a confidence that the psychiatrist already discovered, or if there is a discrepancy between what the patient says and what is found on the Internet.

In conclusion, the psychiatrist-patient relationship is an asymmetrical one. Patients are at liberty to Google their psychiatrist. Psychiatrists are held to a different standard and must perform an online search on a patient only when it is clear that such a search is beneficial to the patient and meets a specific treatment goal. A psychiatrist who notices a strong desire to conduct an online search about a particular patient would do well to restrain the impulse and answer the following questions: Why this patient? Why now? What does this suggest about transference, countertransference, or other aspects of the treatment relationship?

Electronic media change faster than do ethics principles. As soon as we create professional guidelines for interacting with patients by email, telemedicine, and other web-based technologies, new technologies emerge. Rather than looking for rules, allow professionalism, the fiduciary relationship, and prudence to guide your decisions. ■