Psychiatrists Find Home in the Blogosphere

Last year medical ethicist Howard Brody, M.D., published a book, Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, about a subject that would quickly become a moving target.

“The scene was changing rapidly,” Brody said of the mounting public and professional concern about medicine's relationship with the pharmaceutical industry. “It seemed to me that the minute the book was in print, it would be out of date in two weeks. So I thought, What would be a mechanism for keeping me abreast of new developments while also sharing new information with the public?”

The answer was a Weblog, or “blog,” a real-time, online, running commentary on all matters related to the subject of medical-pharmaceutical relationships. He named the blog “Hooked: Ethics, Medicine and Pharma.”

“I set up the blog with one intention—to serve as an update to the book,” said Brody, who is chair of family medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch at Galveston.

At about the same time, his friend and colleague, psychiatrist Jim Sabin, M.D., also began writing a blog called “Healthcare Organizational Ethics.”

“I had been thinking about writing a blog for a few years, but I put it off thinking that I didn't have the technical expertise to do it,” Sabin said. “Then a year ago I made the decision to end my clinical practice. When I really bit the bullet and started to come to terms with the end of clinical practice, all of a sudden instead of dithering about doing a blog, I decided that the only way I would learn about it is by doing it.

“In retrospect I can see there was a connection between the very emotionally meaningful decision to wind up my clinical practice and starting the blog,” Sabin said. “It struck me that there is a deep underlying connection in the area of reaching out to people and making connections. Clinical practice, of course, is about making connections. And in its own way, blogging has something of the same structure.”

Sabin's and Brody's experience underscores two features of blogging—the ability to stay with an evolving subject on a daily basis over time and the capacity to connect in a new way with a universe of Internet surfers looking for thoughtful discourse. These features may account for the popularity of blogging and for turning the medical and health care“ blogosphere” into a new force for shaping public opinion.

Putting a figure on the number of blogs that are written by psychiatrists and other doctors or are focused on medicine, science, and health is impossible; but it is emblematic, perhaps, that Webster's Dictionary—the old-fashioned one you hold in your hands—has an entry for “blog” and defines it thus: “a Web site that contains an online personal journal with reflections, comments, and often hyperlinks provided by the writer.”

It is telling as well that Health and Human Services Secretary Mike Leavitt has his own blog on government policies related to health care.

“We live in an era when information has made a basic change,” said Leavitt in an online symposium titled “The Health Blogosphere: What It Means for Policy Debates and Journalism,” sponsored by the Kaiser Family Foundation. “It used to be we would go to libraries and universities because... they stored and passed on and enhanced information. In the information age, information goes where people are, and public policymakers need to do the same.”

“Do I expect that blogs are going to be a significant part of public policy in government in the future?” he asked. “Absolutely. How? I think we are all figuring that out.”

Even Aunt Min Can Do It

One fact that has certainly contributed to the growth of the blogosphere is that starting a Weblog now requires next to no technical expertise. Many Web sites offer blog-starting tools that can be employed by the most naïve computer owner.

“Basically, it's set up in such a way that Aunt Min can start her own blog and put up pictures of her family,” said Brody about Blogspot at<www.blogger.com>, the Web site that hosts Hooked. “If it were technically difficult, I wouldn't be doing it.”

“If you can use e-mail, you should be able to start your own blog,” agreed “Roy,” a clinician who is one of three psychiatrists anonymously hosting a blog called Shrink Rap. “It is devoted to everyday issues in psychiatry, ranging from private practice to forensics to general-hospital psychiatry—what Roy, who asked to remain anonymous for the purposes of this article, called the nuts and bolts of practicing psychiatry.

The psychiatric threesome also produces a podcast called My Three Shrinks.

A sample of the topics posted on Shrink Rap includes “When Lawyers Call,” “CPT Billing Codes for Psychiatrists and Psychotherapy,” “Why Docs Don't Like Xanax,” and“ Write on that Slate?”—a posting that addressed the concept of the therapist as a “blank slate” and asked such questions as the following:

“How exactly does it damage the patient's treatment if he knows some information about a psychotherapist's personal life? Do we really truly believe that there is a difference in treatment outcomes if a therapist wears a wedding ring or doesn't? If he answers a question about where he went on vacation or if he has children?”

“The goal was to make the blog a place where psychiatrists could talk about issues that affect them on a daily basis,” Roy told Psychiatric News.

It Takes Passion

Weblog writers agreed that blogging can be pleasurable, but“ it's demanding,” Sabin said. “It's absolutely clear that the more you post, the more readers you get. The blogs with the highest readership have postings once or twice a day. My aspiration is to post three times a week, and I don't accomplish that week in and week out. So it's fun, but it's work.”

Sabin, who has written books including Setting Limits Fairly and No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence, has devoted a career to exploring how medical resources can be ethically allocated across a population (Psychiatric News, June 3, 2005).

He is director of the ethics program at Harvard Pilgrim Health Care and a clinical professor in the departments of ambulatory care/prevention and psychiatry at Harvard Medical School.

“One of my missions on the blog is to contribute to detoxifying the topic of including cost as a component when we think about the ethics of health care,” Sabin said. “So there are a lot of postings dealing with cost that have in common the theme of encouraging or delineating ethically robust ways of addressing the topic.”

Postings on Sabin's blog include “Why We're so Ineffective in Controlling Healthcare Costs,” “Learning How to Ration,”“ Technology Running Amok,” and “Avastin 1/Cost Control 0.”

The last of them was a posting on July 8 about the anticancer drug Avastin:“ Only in the U.S. is it possible to ask 'When, if ever, should cost come into the equation?' with regard to a drug that produces ambiguous benefits at best for which billions of dollars are spent.”

Psychiatrist Daniel Carlat, M.D., who writes “The Carlat Psychiatry Blog: Supporting the Search for Honesty in Medical Education,” agreed that without an abiding interest in the subject matter, the Weblogger will have a difficult time sustaining a successful site.

“Unless you feel passionately about your blog subject, chances are you are not going to continue to be successful,” said Carlat, an assistant clinical professor of psychiatry at Tufts University School of Medicine and cochair of the CME Committee of the Massachusetts Psychiatric Society.

Bloggers who spoke with Psychiatric News said that there are countless Weblogs given over entirely to spleen; the Internet is a safe haven for all manner of rants and raves.

But thoughtful, articulate bloggers typically find each other in cyberspace, trading posts and building up a community of readers and writers.

“The thing that's interesting is that out in the blogosphere there is a club, and I'm now a member of it,” said Brody. “I have these fellow bloggers, and we exchange things. If one of us posts something that attracts interest, someone else may use it. These are careful, thoughtful people doing their blogs. They are not just being incendiary, but are trying to back up what they say.”

Sample of Medical Blogs on the Web