Emergency Medicine in the Blogosphere: The Irreverent Wit of the Specialty’s Unofficial Voice
Article Outline
- The Perils of Blogging
- Unintended Influence
- Blogging in Anonymity
- The Ethics of the Weblog
- The New Generation
- Reaching Maturity
Dr. Allen Roberts, an attending emergency physician at Harris Methodist Fort Worth Hospital, had a problem. He’d just raised the ire of the nurses who work with him – and many who don’t—by posting a provocative entry to his popular GruntDoc blog (www.gruntdoc.com) titled “The Lifesaving Foley.”
In August of last year, he decided to write about “a peculiar phenomenon” he’d recently noticed with his nursing colleagues. “I’ll be in the middle of a code, look around and see a nurse studiously inserting a catheter into the patient,” he wrote. Then, he added, “We’ll be getting ready to intubate an agitated patient; I look and see the nurse is busy intubating Mr. Johnson.” And then Roberts took a jab he later regretted:
“I have no idea why. Really, I think they’re stressed out, and want to ‘Do Something.’ They see a task they’re comfortable doing, and so they do it. Indication or not, right time or not, utility or not. I’ve taken to calling it The Lifesaving Foley, for obvious reasons, though I don’t think it’s saved a life yet.”
Oops. Comments from, shall we say, moderately peeved nurses came fast and furious to the GruntDoc blog. A week later he posted a mea culpa entry to the blog titled “Some Nurse Love,” and listed a number of reasons why he appreciated nurses.
“I try not to write anything on the blog that I wouldn’t want to see on the front page of the newspaper,” Roberts said. “But in that case I don’t think the nurses were amused.”
The Perils of Blogging
Such are the perils of blogging, the practice of writing journal-like entries for a personal Web site that anyone in the world with a computer and Internet connection can read. The term blog is short for weblog, first coined in 1997 by Jorn Barger, an early blogger. The phenomenon started gaining public prominence in 2001 and exploded beginning in 2004, when the number of blogs “tracked” by the blog-searching service Technorati increased from a few million to more than 60 million today.
Although this “blogosphere” is still growing, the pace of its expansion has ebbed. Some 100,000 new blogs are created each day around the world, but many other would-be bloggers have abandoned their projects, perhaps finding the task of generating new content too arduous, or running out of ideas. Many, if not most, blogs are largely irrelevant to a broader audience, being more like online diaries. But for those dedicated to their craft and writing about serious issues, blogging has essentially allowed an individual to turn a personal computer into a virtual printing press.
As blogs have multiplied in numbers, some of the most influential writers have begun revolutionizing politics and ratcheting up criticism of the mainstream media. But their effect on medicine, and emergency medicine in particular, is less clear. Because new blogs pop up every day, and older ones are left to fallow, it is impossible to provide a precise census. Still, there are easily hundreds of medical blogs written by doctors in the United States, and probably at least a few dozen written by emergency physicians that concern medicine.
Unintended Influence
Emergency physician bloggers interviewed for this article almost uniformly said they took up blogging on a lark, not to change the face of the specialty. However, most of the emergency physicians whose blogs are widely known within the online medical community said they do raise substantive issues from time to time, perhaps most notably the issue of universal health care, which is understandably close to the hearts of emergency department (ED) doctors.
This is one of the passions of Dr. Liam Yore, an emergency physician in the Pacific Northwest who writes a blog titled Movin’ Meat (www.allbleedingstops.blogspot.com).
“Part of why I do this, the most essential part, is that I’m just telling my story,” he said. “If I were to say I had a mission, it’s not to educate, it’s not to entertain, it’s just to express my personal experience. But sometimes I do get into the politics of health care, and in that case I’m definitely advocating within the physician community.”
GruntDoc and Movin’ Meat are among the most influential emergency medicine blogs, along with Scalpel or Sword (www.scalpelorsword.blogspot.com), Trench Doc (www.trenchdoc.com/trench) Fingers and Tubes in Every Orifice (http://www.fingersandtubesineveryorifice.blogspot.com) and a handful of others. These blogs average anywhere from a few hundred to several thousand visits per day. Few emergency medicine bloggers make money off this modest traffic; indeed, most have decided against accepting advertising.
“The revenue potential is not huge, and this isn’t something I’m doing because I need the money,” Yore said.
Blogging in Anonymity
These blogs are often irreverent. Trench Doc, for example, links to the American College of Emergency Physicians (ACEP) home page from his blog, but labels the organization as “EM’s snobby, rich uncle.” (The American Academy of Emergency Medicine is also linked, and labeled as “EM’s crazy uncle.”)
Some blogs are semi-anonymous—neither Roberts nor Yore have their name on their blogs—but at least a handful of their colleagues know what they’re doing online. Whether administrators know or even care about these activities remains something of a gray area. Roberts said the administrators of his hospital don’t seem particularly interested in blogging. Yore said he’s the administrator of his ED so it’s less of an issue.
But physicians who are less measured in the tone of their blogging output often choose to avoid any conflict by remaining completely anonymous. One of the most widely read anonymous emergency physicians is the author of Fingers and Tubes. Calling himself “Charity Doc,” he lists his location as “Crack City Medical Center” and includes this disclaimer on his blog: “I once had aspirations to make a difference in the world, now I just work at it one guaiac card at a time.”
Charity Doc said he could only continue blogging if his “cloak of secrecy” were maintained.
“We’ve all been through it, experienced the joys, jubilation, and frustrations of it all. I chose to blog about it because the stress of the job got to the point where I had even wrote a letter of resignation and was about to quit medicine altogether,” he said. “My insignificant blog has no altruistic endeavor nor any benevolent intent. It’s just a forum for me to mouth off, and the only way than I can continue to do so is to do it anonymously.”
Inevitably most emergency medicine blogs include descriptions of patients. A doctor will present a case, and make a comment. Often the point is simply to vent—consider this snippet from a screed by the anonymous author of Scalpel or Sword for a patient who got tired of waiting and turned abusive:
“Oh, and yelling to the world that you have to go to work at 7:30 a.m. does not buy you any sympathy from the staff or your fellow patients. Are you suggesting that you are more important than these other folks, or that they don’t have to go to work? How insulting. Get your obnoxious (but uninjured) ass back in your room or leave. We don’t really have a preference.”
Such rants not only provide a release for a frustrated doctor, they can provide support and validation for hard, sometimes thankless, work. After posting that rant, the author received 13 supportive comments, such as “Wow! You DA man!” Such free, emotional releases are why a number of emergency physician bloggers, including the author of Scalpel or Sword, prefer anonymity.
“I would never want to embarrass my hospital, my patients, or my bosses, and I certainly wouldn’t want to lose my job over anything I might say,” said the Houston-based emergency physician. “So I change enough key details in each of my rants to provide a layer of camouflage to the average reader. Often cases I present are composites of several different patients or situations anyway. But they are all based on actual circumstances I have personally encountered. I don’t provide any personally identifiable medical information about any of my patients, so I avoid violating the strict HIPAA laws.”
The Ethics of the Weblog
Medical blogging is an ethical activity, said Arthur Caplan, a professor of bioethics at the University of Pennsylvania. Caplan also contributes to blog.bioethics.net, a blog by editors of the American Journal of Bioethics.
They are healthy as long as doctors adequately disguise patients and institutions. He compared them to an extended form of chatter and conversation—but cautioned they should be treated more as gossip than a trustworthy source of information.
As for advice to doctors considering starting a blog, Caplan said, “They should have a sense of humor about it.”
Yet as Caplan’s own blog shows, there is a place for serious discourse in medical blogging. It’s a way for organizations and companies to embrace new technologies, and show they are willing to have an open dialogue with members and consumers. In short, it’s a way to connect with a younger generation.
ACEP, too, recently began testing the blogging waters by launching Gardner’s Gate, the organization’s first “official” blog. Begun in November 2006, the blog is written by Dr. Angela Gardner, secretary-treasurer of ACEP and an assistant professor of emergency medicine in the Department of Surgery at the University of Texas Medical Branch at Galveston, TX.
“I was thinking about ways to bring ACEP into the 21st century,” Gardner said.
Younger physicians, she noted, have a different philosophy about medical meetings. They’re more Web savvy, and many choose to get information about their profession through the Internet rather than attending large meetings.
“For that group we need a new way to make ACEP available, we need to reach an audience we’re not reaching otherwise,” she said.
Traffic to Gardner’s blog has so far been modest, but that’s normal for a start-up. Importantly, she’s been welcomed to the blogosphere by more influential authors such as GruntDoc, who have linked to the ACEP site. It’s made Gardner’s Gate part of the online discussion rather than a lonely voice shouting in the wilderness.
Gardner describes her blogging as a “learn-as-you-go” process, and admits that being associated with ACEP has led her to be cautious. In her first months she posted on a variety of topics, from philosophical to medical to political issues. Perhaps not surprisingly, she has found that the controversial topics have generated the most traffic and interest.
“I’ve started to try and put more insider baseball stuff in there, but that’s a tricky territory,” she said. “It’s all my opinion, and yet I represent ACEP, so I need to be careful.”
Gardner’s experiences mirror those of other medical bloggers who have found that the Internet is often more of a water cooler than a place for serious medical discussion. As she has guessed, it’s also a place to attract the attention of a younger generation of doctors.
The New Generation
One such physician is Nicholas Genes, a second-year resident in emergency medicine at Mount Sinai Hospital in New York. Genes is the author of Blogborygmi, (blogborygmi.blogspot.com) a play on the medical term for gut rumblings. Genes said he decided on a career in emergency medicine partly because of the influences of blogs like GruntDoc. He says the Web remains an important source of information invaluable to his up-and-coming career.
“The medical blogosphere reminds me of a cocktail party, or maybe an old-time physician’s lounge, although I’ve never really seen one,” he said. “It’s invaluable to a resident like me, to listen in on EM attendings comparing patient stories, psychiatrists when worrying about overmedicating children, internal medicine docs excited about a new clinical trial, the surgeons griping about inappropriate ED consults. You can’t get this kind of insider’s perspective by picking up a journal or reading an editorial. It keeps me connected to the other specialties, and orients me to what’s important in my specialty.”
Other emergency physicians who blog also said they don’t generally read blogs to enhance their technical skills. But almost everyone interviewed for the article mentioned that blogging made them identify with patients more closely, the issues they face in waiting rooms, and that this experience had probably made them more empathetic physicians.
In the last 2 years blogging has grown up, transitioning from grass roots to the mainstream. In the early days, individuals operated the most popular blog sites on the Web. Now, many of the top 100 blogs are operated by traditional media sites such as the New York Times, Yahoo! News, CNN and MSNBC.
Reaching Maturity
A similar evolution is probably underway in freewheeling world of emergency medicine blogging. Gardner says she foresees the day when ACEP has multiple blogs, with an emphasis on medical residents and younger physicians writing about their experiences in health care. It’s possible that hospitals and other institutions will someday formalize guidelines for employees who operate blogs.
Allen Roberts also sees a role for blogging within institutions, and he has recently created a password-protected blog for physicians and other employees in his ED. It’s a more efficient bulletin board, a better way to share information like division meeting notes, or even more mundane things like the combination to the break room.
“It’s a useful way to ensure that everyone gets the same information,” he said.
One of the first emergency medicine bloggers, Roberts has operated GruntDoc for about 5 years now. Initially he used it to blow off steam, but as more people discovered GruntDoc’s identity he began self-censoring more, and stopped writing when he was angry. His blog got popular enough that he even accepted advertising for a few months, but soon gave that up because blogging began feeling more like work than a hobby.
And if it comes to a decision between losing his job and keeping the blog, it’s an easy choice.
“I’ll do this until it bores me, or it interferes with my employment,” he said. “If it does that, then it’s out. I have no high or noble goals, I’m not trying to educate or enlighten, it’s just my journal on the Internet. This is for me, and I’m flattered and amused that other people like it.”
PII: S0196-0644(07)00375-7
doi:10.1016/j.annemergmed.2007.03.014
