Mano, Max S.

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Cadernos Espinosanos (E-Journal)

Clinics 78 (2023) 100156journal homepage: https://www.journals.elsevier.com/clinicsCommentsIf you can’t kill the beast, tame it: Tips forsurviving WhatsApp® in medical practiceTable 1Definitions of a whatsdoc practicing a whatsmedicine.Communicates with patients by instant messaging app >90% of the timesConcedes to do subtle ‘whatsconsultations’ and ‘whatsprescriptions’ without alwaysrequiring a formal consultation appointmentResigns to the impossibility of deviating the messages when going on vacationand/or off work hoursIs constantly swamped with test reports that should never have been sent viasocial media (also because of lax confidentiality standards)Does many small tasks that in the past were fully delegated to a clinic assistant(secretarization), such as: Helping patients to schedule appointments when the switchboard fails or is off-hours Taking requests of non-urgent / administrative medical reports via instantmessaging Accepting frequent interruptions to open a patient’s medical chart to verify list ofworkups for the next consultation appointment that the patient has lost orforgotten Accepting frequent interruptions to copy and paste a login/password to check anonline test report of a patient Accepting frequent interruptions, even when off work, to generate an electronicprescription of a prescription drugI have previous addressed the potential harms of unrestricted accessto test reports on patients with cancer’s emotional well-being and howthis problem is amplified by Instant Messaging (IM) communication.1,2Although the use of IM in patient-physician communication appears tobe on the rise everywhere, in Brazil this phenomenon has reached pro-portions that are unknown elsewhere − with many physicians estimat-ing that greater than 90% of their interactions with patients now occurvia this app.The pressure from patients to retire our old pages and mobile phonesin favour of a texting device started to mount during 2013-2014 − flour-ishing years of WhatsApp® in the region; and many physicians (likeme), after years of reluctance, eventually surrendered. Back in 2014, Iand my team embarked on a trial period that should be followed by anassessment. The initial experience was mixed, with an observed reduc-tion in the frequency of voice calls, which were compensated by a sharpincrease in text messages − probably perceived as less intrusive bypatients. However, over time, the content of the interactions tended toslide away from pure medical issues to include demands for non-urgentmedical reports, appointments and every sort of non-medical issues thatwere previously addressed by the administrative staff; like a new chapterof the ongoing process of ‘secretarization’ of the medical activity − ontop of the electronic health records and insurance paperwork − nowreaching a new dimension with the practice of a ‘whatsmedicine’.Another intriguing fact was the large number of text communicationdelivered during off-work hours (probably when people have the timeto send them). One curious and recurrent pattern was that of messagessent at night − very commonly on Sunday − stating that ‘this is just toanticipate the tasks of the week ahead’; fortunately, at least the physi-cian ‘doesn’t need to read them right away − next morning will be fine’.Frequently, these messages come with a companion list of test reportsand audios. I and my team have always perceived these unnecessarymessages as particularly disturbing as they threaten a much-neededperiod of mental rest for the oncologist.Another emerging synergism that deserves attention is the onebetween WhatsApp® and new electronic prescriptions of prescriptiondrugs; now requests for renewals or new prescriptions pop up on thescreen at any time. Some health insurers have also started requiring lab-oratory or imaging orders by electronic prescription only, aggravatingthe problem.The recommendations from health authorities in Brazil regarding theappropriate use of social media (which includes Facebook’s What-sApp®) have been rather ambiguous − stating that ‘confidential results(i.e., almost all!) should not be sent via social media’, which physiciansusually comply; however, the flow of information is often the reverse −with patients downloading all sorts of test reports (including sometimeshighly confidential gene test results) and naively forwarding them viaIM. Physicians are usually aware that no prescriptions or consultationscan be issued via WhatsApp®; however, what distinguishes an actualhttps://doi.org/10.1016/j.clinsp.2022.100156Received 29 October 2022; Revised 4 December 2022; Accepted 8 December 20221807-5932/© 2022 HCFMUSP. Published by Elsevier España, S.L.U. This is an open a4.0/)medical act from a piece of advice, clarification or complementary infor-mation is often blurry.Table 1 depicts the key points that characterize the practice of a‘whatsmedicine’. The adoption of WhatsApp® to communicate withpatients is a process that consolidates very quickly and is difficult toreverse. Once a physician surrenders and adjusts his practice to accom-modate these demands (Table 1), this is a clear sign that he is alreadypractising a ‘whatsmedicine’. I estimate that meeting 3 or more of thesecriteria is sufficient to establish the diagnosis.In 2020, as a reaction to this new reality, I and my team decided toadopt the WhatsApp Business® tool,3 which has several functions thatallow the configuration of restrictions and automated responses. In ourexperience, this does not resolve, but attenuates the burden of thesedevices on practising physicians’ routines and personal lives. In Table 2,I suggest a set of practical measures that might help you survive What-sApp® in medical practice.In a previous article,2 I and my co-author have briefly addressed theimpact of widespread digitalization on physicians’ well-being and men-tal health − which haven’t been in great shape for years.4−9 With fewstudies published to date, we were unable to specifically evaluate theimpact of WhatsApp® on rates of professional burnout; however, consid-ering the scenario herein depicted, one can assume it won’t be good. Weare about to start a prospective study addressing both patients and phys-icians’ perceptions on this subject.In summary, the use of WhatsApp® or similar platforms continues tospread and is gradually taking control of patient-physician communica-tion. The author of this piece is sceptical about the effectiveness ofenforced rules to regulate the practice − because the nature of the app(with a bilateral communication and no optional blockade of files/voiceccess article under the CC BY license (http://creativecommons.org/licenses/by/Table 2The golden rules for surviving instant messaging apps in medical practice.aMeasure How to accomplish this Why this is importantEmploy a corporative mobile phone number with clearinformation about work hoursConfiguration in app’s ‘account settings / businesshours’Failure to do this may affect your ‘away from work’ hours andvacation periodsConfigure an automatic message stating that messagessent ‘off hours’might not be read (in case of a medi-cal issue requiring immediate medical attention,a phone call is always required)Configuration in app’s ‘account settings / away times’ To ensure at least some rest time during off hours and limit dis-ruptions to true medical issuesTo ensure that true urgencies/emergencies will never be missedState that issues requiring immediate medical attentionalways require a phone callConfiguration in app’s ‘account settings / businessdescription’You can easily miss a text message that could turn out to be amore serious medical situationMake it clear that test reports should never be sent viasocial mediaConfiguration in app’s ‘app account settings / businessdescription’In many countries this is forbidden or highly discouraged (due tolax confidentiality security in most of these apps)Request patients to avoid audio messages Configuration in app’s ‘app account settings / businessdescription’Audios are highly time consuming and, in many situations, cannotbe listened toTurn off the app ‘notifications’ Configuration in ‘phone settings’ Constant notifications are highly distractive and may sometimeswake you up in the middle of the night for a non-urgent issueRequest patients to never request non-urgent reports bytext messageConfiguration in app’s ‘app account settings / businessdescription’Administrative demands should only be made by email or phonecall to a clinic assistantEducate patients that text messages (especially testreports) will never replace a formal consultationappointmentExplain to your patients how to rationally use thesedevices in relation with their treatmentsYou don’t want to become a ‘whatsdoc’, and this practice can alsobe dangerous to patients themselvesa Though the principles may be valid for any instant messaging app, the specific recommendations in this table apply only to WhatsApp Business®.M.S. Mano Clinics 78 (2023) 100156messages) makes this type of control unrealistic. A total ban of this typeof patient-physician communication by all medical societies and healthauthorities is the only reasonable measure − one that will protect phys-icians’ well-being and mental health and patients from potential confi-dentiality breaches and addiction in accessing test reports to obtain animmediate − and potentially misleading − response to their diseases’condition. In the meantime, I herein propose a set of measures thatmight help to attenuate the problem.Conflicts of interestThe authors declare no conflicts of interest.References1. Mano MS. Patient-accessible test reports in times of instant messaging communication:progress or an additional emotional burden? Lancet Oncol 2021;22(10):1365–6.2. Mano MS, Morgan G. Telehealth, social media, patient empowerment, and physicianburnout: seeking middle ground. Am Soc Clin Oncol Educ Book 2022;42:1–10.3. WhatsApp business https://www.whatsapp.com/business/?lang=en Accessed on 01/10/2022.24. Berg S. Physician burnout: which medical specialties feel the most stress. https://www.ama-assn.org/practice-management/physician-health/physician-burnout-which-medi-cal-specialties-feel-most-stress. Accessed October 1st, 2022.5. Banerjee S, Lim KHJ, Murali K, Kamposioras K, Punie K, Oing C, et al. The impact ofCOVID-19 on oncology professionals: results of the ESMO Resilience Task Force surveycollaboration. ESMO Open 2021;6(2):100058.6. Lim KHJ, Murali K, Kamposioras K, Punie K, Oing C, O’Connor M, et al. The concerns ofoncology professionals during the COVID-19 pandemic: results from the ESMO Resil-ience TaskForce survey II. ESMO Open 2021;6(4):100199.7. Lim KHJ, Murali K, Thorne E, Punie K, Kamposioras K, Oing C, et al. The impact ofCOVID-19 on oncology professionals—one year on: lessons learned from the ESMOResilience Task Force survey series. ESMO Open 2022;7(1):100374.8. Thomas Craig KJ, Willis VC, Gruen D, Rhee K, Jackson GP. The burden of the digitalenvironment: a systematic review on organization-directed workplace interventions tomitigate physician burnout. J Am Med Inform Assoc 2021;28(5):985–97.9. Mheidly N, Fares MY, Fares J. Coping with stress and burnout associated with telecom-munication and online learning. Front Public Health 2020;8:574969.Max S. Mano *Breast Cancer Group Leader, Grupo Oncoclínicas; Faculty ‒ ESMO BreastCancer Group; Faculty ‒ Academy of Leadership Sciences Switzerland(ALSS); Vice-chair, LACOG Breast Cancer Group, S~ao Paulo, SP, Brazil*Corresponding author.E-mail address:max.mano@medicos.oncoclinicas.com

If you can't kill the beast, tame it: Tips for surviving WhatsApp® in medical practice

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If you can't kill the beast, tame it: Tips for surviving WhatsApp® in medical practice

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Cadernos Espinosanos (E-Journal)