Insights November -0001

Who Will Be My Friends?

Neil Seeman

With the emergence of the mega-social networking site Facebook, it seems everyone's "friends" with everyone else these days. A fascinating paper by Dr. Sachin H. Jain in the New England Journal of Medicine asks: Is it professionally acceptable for a physician to accept a "friend request" from his or her patient?

There is no consensus answer. In a Medscape discussion prompted by a blog post by Dr. Alok Khorana [Link requires registration], one contributor says: "We have a practice page on Facebook that we use to communicate directly with our patients … don't be scared to be a 'normal' person and talk to your patients."

A dermatologist takes a different view: "I strongly resent befriending patients or their relatives on Facebook or any other social network. Recently I curtly told one person to avoid this as it is unethical and against the norms of the oath."

Similar debates about the limits of friendships, and whether professional-client relationships should extend online, have surfaced in law and business and academe. Should a senior executive "friend" a 25-year-old new employee? Is it rude to deny "friend requests" from casual acquaintances? And if I accept these people as my friends, must I be continually exposed to their beer-swilling college frat photos? And why do my supposedly mature friends send me juvenile "alerts" about their mundane musings (e.g. "Got a craving for pop tarts…yummy!")? Or post mushy love-notes to their spouses on Facebook's public walls?

Putting aside the question of whether our online friendships are ruining our real-life ones, it's worth asking, "What is a friend?" This matters considerably in healthcare, where showing empathy toward one's patient can improve care; and where bonding with a burned-out co-worker, online or off, can improve workplace health.

Defining Friendship Down

When introducing a real friend to a new acquaintance, I often feel the need to call my friend "a dear friend" or a "close friend." "Friend" requires an adjective these days, since otherwise it feels empty. We've dumbed adult friendships down.

In my three-year-old daughter's pre-school, everyone calls everyone in their class a "friend". This is blessed behaviour when seen in children: "Daddy, I need to say bye to all my friends before we go home." For adults, friendships enjoy special status. If you are very lucky, you will make one meaningful friendship for every year you live, and you may have only one or two or three who stay with you for a lifetime.

When we dumb friendship down, on Facebook or in everyday life, we risk confusing people who may misconstrue what is signified by that relationship. This, in my view, is the best reason not to friend your patient or your client. When in a trust relationship (what lawyers fancily call a "fiduciary duty"), your client or your patient may be vulnerable. He or she may consider a curt note from you on Facebook to be threatening. "What have I done to offend him?" they might be thinking. "Will he delay my appointment? Treat me rudely? Refuse to refill my prescription?"

All patients, all clients, are not the same. My mother (Mary Seeman), a physician, suggests that "a good rule to follow is for the doctor always to be 'abstinent' - in other words, she should not be 'getting something' out of her relationship with her patient other than the satisfaction of doing as good a job as possible. Patients should not be sources of entertainment, information, news, stock market tips, romance, actual friendship, or warm feelings."

My view is that professional codes for self-regulated professions forbidding romance with patients (or clients) aim to protect the most vulnerable among us. And vulnerability in affairs of the heart is not always self-evident. Hulking football linemen - I knew at least two in college - can cry over a woman who politely denies them a date. "Let's be friends" can be the cruelest of lines.

Freddy and Friendship

We first learn about the complexities of managing friendships as children. In Who Will Be My Friends?, a children's story by author-artist Syd Hoff (most famous for the 1958 classic, Danny and the Dinosaur), young Freddy arrives in a new neighbourbood and looks for friends. "Who will be my friends?" he wonders. He asks the policeman, the mailman, and the street cleaner. But they are too busy working. Unfazed, Freddy saunters over to the playground and asks the boys playing ball if they will be his friend. They ignore him and keep playing.

Only when Freddy starts playing cheerfully by himself - throwing the ball high and catching it - do the other boys notice him and invite him to be their friend. There are many popular children's books today with a similar plot. In Rainbow Fish by Marcus Pfister, a beautiful fish is shunned until he begins to give away his glittering scales to other fish. I recommend Little Smudge by Lionel Le Neouanic, where a lonely black "little smudge" sulks when colourful squares and circles reject his friendship; yet when he dazzles everyone with his shape-shifting talents, he makes friends. The message: you have to work at starting, and nurturing, a friendship.

The Rules Don't Change

The same rules of friendship should apply online and off. A friendship is not the same as a series of client meetings in a downtown office. The spirit, if not the letter, of most professional ethical codes would suggest that "friending" a patient or client on Facebook is inappropriate. I consider it inappropriate since it can invite miscommunication, disappointment and expectations of favouritism.

One never knows whether one of your patients or clients might harbour resentment or disappointment or fear or vulnerability if the online friendship crumbles. This may happen innocently: it takes time, which few professionals have much of, to stay on top of email and social networking correspondence. And to your client or patient, that fragile online friendship may mean much more than it does to you.

About the Author(s)

Neil Seeman is a writer, and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.


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