Internet Intimacy and Betrayal (or My Take on the TNT Affair)

A long, long time ago -- about a month -- just before the dinosaur in me decided it wanted to blog, there was a bit of an uproar over a blog called The Naked Tomato (no link.) To summarize the saga, an 18-year-old woman posed online as a Pediatrics Resident, became close to several other bloggers, disclosed some very personal stuff (now uncertain how much was true) and led at least one other blogger to disclose a very personal trauma of her own. When the truth finally came out completely (after the denials and the accusations) several bloggers felt betrayed.

Flea has found himself upset when families transfer their child out of his care. On one occasion he blamed himself for a minor mistake that he felt caused the rift, but the same thing has happened to me many times over the years, even when everything seemed fine. I have felt betrayed when a patient unilaterally ends our relationship.

Ripple of hope, formerly Difficult Patient, has elaborated on her blog about a doctor who dismissed her from his practice -- unjustly, in her opinion and the opinions of others, including me -- for her supposed misuse of controlled substances prescribed by him. Her doctor told her she had betrayed him; he blamed her for his possible liability, and told her she had "put his wife and family at risk."

I have had patients come to me seeking drugs, lying to me to obtain them. I have been fooled. Other doctors in this situation have told me of their anger at "having been betrayed" by these patients.

There must be an obligation in order for there to be a betrayal, so who exactly is betraying what in these scenarios?

The doctor-patient relationship is inherently asymmetrical, emotionally speaking. As much as we doctors derive deep emotional satisfaction from our relationships with our patients, they -- our patients -- don't really owe us anything emotional. They are free to transfer their care to other doctors if they wish, for any reason(s) they choose. It's a painful lesson that, with luck, gets learned early in a career (cough*Flea*cough) and even when learned well, doesn't prevent a pang on seeing that "Please send my records to..." note from a long-term patient. But I'm not so sure I could call it "betrayal."

What about folks who lie to me to get drugs? I quickly realized that the anger I felt was actually at myself for having been fooled. Over the years, I decided to be nicer to myself. I'm only human, and as hard as I try not to be, I'm going to be caught up in someone's sad tale from time to time. (Much less now than when I was younger, so obviously I'm doing something right.) Rather than getting angry at the patient for "betraying" me, I've learned to take it in stride.

And Ripple's doctor? That was emotional blackmail, pure and simple. It is never legitimate to invoke one's feelings or those of one's family in the context of a doctor-patient relationship. If anyone was betrayed, it was the patient.

What about TNT? What did she owe a bunch of strangers in the blogosphere? That gets into the concept of intimacy (thanks to Moof for an enlightening series of emails.)

Here on the internet, all we have are our words (and pictures; see TundraPA) and despite the ubiquitous warnings, we also all begin with the presumption of honesty. We are presumed to be real people telling the truth about ourselves, and as it turned out, TNT wasn't; this despite the fact that the bond others forged with her was real. Here's how I phrased it to Moof: think of "internet intimacy" as a "promissory relationship". I could say to her, "Hey I'm going to be in your neck of the woods; let's meet for coffee," and know that the relationship would be the same nose-to-nose (her words) as it is nose-to-screen (mine.) The kicker is that this potential has to be real. I really am a family doc in solo private practice, as Moof could discover beyond a shadow of any doubt if we were to meet. As it happened, TNT could not do the same.

Here's one more analogy I came up with: paper money is backed by the full faith and credit of the United States Government. (Leave it for now, please; this isn't a political post.) Dollar bills aren't the same as gold, but they are, for all practical purposes, readily exhangeable enough so that they are functionally identical. The existence of counterfeit bills does not undermine that basic equivalence. Likewise, internet friendship -- intimacy, if you will -- can be similarly assumed to be real until disproven. Running across the occasional faker doesn't invalidate the rest of the gifts the blogosphere has to offer.