Problems Moderating Comments Improve but Continue
Physicians are fiercely independent and opinionated. Many have taken to social media platforms to express themselves — sites geared toward medical content containing news-feeds, op-eds, journal articles, and general interest articles. The rise in popularity of medical websites is due not only to the perceived value of their medical content, but also the ability of physicians to post comments online. In doing so, however, websites are vulnerable to misinformation and problems in their comments sections, especially trolling. Physician trolls are bent on “making random unsolicited and/or controversial comments…with the intent to provoke an emotional knee-jerk reaction from unsuspecting readers to engage in a fight or argument” (Urban Dictionary).
Two of the most popular medical websites are Doximity.com and KevinMD.com. Both have similar guidelines for posting and removing comments. Doximity removes comments containing erroneous or misleading medical information; offensive, discriminatory, or unprofessional remarks; off-topic commentary; and violations of the Health Insurance Portability and Accountability Act. KevinMD removes comments at their discretion, as well as comments that receive a certain number of flags from the readership. The website will not publish comments that fall under the following categories:
- snarky, trolling, off-topic, make the same point repeatedly, ranting at doctors, ranting at patients, excessively long, libelous, defamatory, abusive, harassing, threatening, profane, pornographic, offensive, false, misleading, or which otherwise violates or encourages others to violate KevinMD’s sense of decorum and civility or any law, including intellectual property laws;
- “spam,” i.e., an attempt to advertise, solicit, or otherwise promote goods and services; and
- off-topic hyperlinks
Comments close on KevinMD a few days after the article is published. Doximity appears to be open ended, and thus there are more opportunities for comments to spiral out of control. There has been an apparent decline in internet medical diplomacy due mainly to a few trolls who like to swing their clubs at colleagues. The actual percentage of doctor trolls is unknown, but it is noteworthy that roughly four-in-ten U.S. adults have experienced online harassment.
Doctor A is a typical physician troll. Like the mythological troll hiding in his cave, Dr. A is envisioned hiding behind his computer screen, actively going out of his way to belittle colleagues, stir controversy, and cause a ruckus on the internet. Here are a few examples of Dr. A’s demeaning, provocative, rebel-rousing remarks.
· In response to an article that discussed doctors at risk of malpractice claims, Dr. A commented: “Article is useless. Appears multiple countries, specialties, etc., are included. Arrogance and obvious greed are likely components of who people sue.”
· Commenting on an op-ed discussing similarities between Olympians and physicians, Dr. A said, “The whole conversation is absurd…self-congratulatory back patting.”
· Dr. A trashed an article as “utterly useless.” The article discussed several ways physicians may supplement their incomes.
· A physician published a moving essay about a patient who died despite the best possible care. Dr. A remarked, “This doctor didn’t exactly sacrifice anything in her care of this patient. She did a minimal average acceptable job [with] no clue whatsoever if the standard of care was met.”
I even came under attack by Dr. A for my comments related to an article about the importance of primary care physicians as mental health providers. Here is our exchange:
Dr. Lazarus: I like the idea of using at least two simple screening measures such as the PHQ-9 (for depression) and GAD-7 (for anxiety). They are not diagnostic in themselves; rather, they signal the need for further questioning and discussion that may uncover mood and anxiety disorders or psychosocial stressors. Rating instruments administered over time can also be used to track patients’ progress to treatment.
Dr A: Do you have any financial or other conflict of interest disclosures you should make regarding these? I despise questionnaires.
Dr. Lazarus: The GAD-7 and PHQ-9 are in the public domain. I resent your implication that I have any COI [conflict of interest].
Dr. A: Your overwhelming support of two minimally helpful questionnaires raises the obvious question of COIs…I have zero regard for your opinion. Your [online] profile is that of a fame and money-grubbing doctor.
Dr. Lazarus: If you wanted to become a profiler you should have joined the FBI. Instead, you became a troll. I will have no further interaction with you. I hope you do likewise. Goodbye.
A different troll, Dr. B, attacked me simply for recommending psychiatric treatment for a manic patient. A community member, Dr. C, interceded and chastised the troll. Here is the exchange:
Dr. Lazarus: I would recommend just give the patient an anti-manic drug and forget about trying to find sense in the psychosis.
Dr. B: The use of antimanic agents is presumed Dr Lazarus. Or antipsychotics. But the internal experience is also important during the recovery and later rehabilitation. Also to prevent relapse and maintain therapeutic alliance. I trained in a unit doing both. And it’s fascinating to observe later how the insight develops and it is impressive how many patients feel the understanding provided by empathic psychiatric nursing as well as psychotherapeutic alliance has made. People are whole. They are not just meds.
Dr. Lazarus: I don’t think it is appropriate for you to lecture me or for you to assume (incorrectly) that I negate the importance of patients’ internal experiences. Your comments should be aimed at diffusing tension, not creating it. Thank you.
Dr. B: I am sorry you took offense. I would not question your technique. I simply responded to your certitude that meds are all. It was not meant to you. I find your comments usually very insightful and erudite. But I am familiar with dismissive attitudes towards psychotherapeutic approaches and perhaps you assumed medication was not part of it.
Dr. C: Dr. B, I must say that among your many comments that I encounter [online], you always seem to find some way to poke your fellow clinicians’ egos. You’re at it again.
Recently, I wrote an op-ed about the importance of speaking one’s mind. I felt muzzled while working for healthcare organizations and regretted remaining silent about certain policies that favored business practices over patient care. My op-ed was honest and sincere, so I thought. I wasn’t expecting an onslaught of criticism from Drs. D and E and others. However, once again, a community member, Dr. F, came to my rescue:
Dr. D: I find it hard to believe that you can work for 40 years and “not speak up.” I wonder how many patients were harmed by not speaking up for 40 years?
Dr. Lazarus: Let me assure you that no patients were harmed during my watch…Life in industry for physicians is fraught with conflict and can silence even those with the best intentions. That was the main point of my essay. I’m sorry you misconstrued it.
Dr. E: Uh, actually…she did not misconstrue what you said. And there is also the issue of your essay being internally inconsistent.
Dr. F: Dr. D, did you fail to understand Dr Lazarus’ statement that he needed the job? I think it valiant that he made the efforts he did, many would have taken their paycheck and went home.
I wrote a very personal, reflective essay about gaining confidence as my career progressed. I felt I no longer had to prove others wrong to derive personal satisfaction at work. My essay drew this unsuspecting response from Dr. G: “Wow, existing to prove others wrong? I pity you.”
When I had difficulty finding a psychiatrist to treat a depressed relative, I began to wonder what happened to professional courtesy, the tradition of doctors treating doctors and their family members promptly, often at no charge. Reactions to my editorial were so contentious that the website editors were forced to delete all comments. Still, some community members felt compelled to reach out to me through private messages, clearly divided in their opinions:
Dr. H: To be clear (which I believe you pointed-out), professional courtesy has nothing to do with money and everything to do with being neighborly. It’s about doing the right thing. It’s how I was brought up. Being in private practice, I offer professional courtesy (family medicine) frequently. To the dentist family across the street. To the podiatrist family two-doors up and to the attorneys next door. To the guy next to the clinic who does the taxes for my young staff. On and on. Frankly, it makes my day when I can help. It gives me a dopamine boost to ‘go out of the way’ for someone in need.
Dr. I: So-called “professional courtesy” is the type of favoritism that has ruined the world. It is very much the same as the favoritism practiced by the Mafia, many corrupt politicians, cults, secret societies, white supremacists, and other tribes that think they are better than everybody else, including being better than every other species of living thing. We will continue moving into a worsening world, with wars and extinctions, until we respect others as much as we respect ourselves and “our tribe.” Let us all hope for an end to “professional courtesy,” and work to end the tribal practice, so we can all move towards a fairer world.
Sometimes it’s a fine line between trolling and stating an opposite opinion. The difference is not necessarily what’s said, but how it’s said. Comments made by the medical troll resemble the persona of the mythical troll — angry, dirty, dark and hurtful.
Certain blogs are notorious for attracting trolls, e.g., YouTube video comments and social and professional network forums, including medical blogs. According to Lifewire, “Every internet troll has a different backstory and therefore different reasons for feeling the need to troll a community or an individual on the internet. They may feel depressed, attention-starved, angry, sad, jealous, narcissistic or some other emotion they may not be entirely conscious of that’s influencing their online behavior.” Physicians suffer high rates of burnout, depression and substance use, and in that respect, they are not much different than the general population.
Richard Plotzker, an endocrinologist who blogs at Consult Maven, writes: “Our cyberspace antagonists, some of whom may have some real paucity of self-esteem prompting them to seek it from wherever they can, are really most like the curmudgeons. The trolls all have a life outside the internet. We have no way of knowing who would be our friends if we knew them or who would be given a Scarlet ‘A’ for their next birthday to sew onto the pocket of their white coat so we know to avoid them. Either way, they have only as much influence as we allow them to have. As the eminent psychiatrist Dr. Frankl reminded us, the ability to frame how we respond to a challenge is one of the few things in our absolute personal control.”
Indeed, the best way to deal with trolls on the internet is to ignore them.
My experience as a blogger highlights problems with content moderation apart from disinformation — specifically, problems posed by internet trolls on medical websites. Doctor trolls prevent medical blogs from being a safe space for free expression and diverse perspectives. Problems moderating comments on medical blogs are a microcosm of the problems facing social media giants Facebook, Twitter and others, with the exception that physicians should be held to higher standards than, say, individuals commenting on Facebook. Posting inaccurate, incomplete, biased, or false medical information could seriously harm patients.
To be sure, there have been attempts to fix the problems. Both Doximity and KevinMD are very transparent and post their guidelines. Prior to posting a comment on Doximity, individuals are reminded: “By posting you agree to our Community Guidelines.” KevinMD informs its audience that “comments are moderated before they are published. Please read the comment policy.”
Yet, enforcement has been an ongoing problem due to either a lack of resources or users circumventing the rules. Medical blogs need to tighten their screening processes, remove the trolls, and ensure only accurate information is posted and shared.
Some progress is being made. Dr. A was flagged, and his commenting privileges were restricted.