Enoch Choi, MD

The peak of the Sakura season of cherry blossoms blooming this week provide hope that “This, too, shall pass.” The Japanese people have suffered a triple threat, the worst within recent history: the strongest earthquake, the tallest tsunami, the worst nuclear disaster. It has been a perfect storm.

Japan—the country most prepared for natural disaster&mdash; initially fell flat in responding to each of the three crises. But the resilience of the Japanese people, and their civility, has shone a light through the rubble to the hope reflected by the yearly return of these softly falling cherry petals. We can learn much from not only their charitable character, but also about how their culture has limited the help that has been offered to them.

It reminds me of Haiti, where last year 300,000 died in a moment, and 2 million remain displaced. I am the medical director of Jordan International Aid, a 501c3 organization that sent nine teams of more than 200 physicians, nurses, and supporters to help in Haiti last year. We found Haitians who had never seen a physician in their lives, and we had the privilege of caring for them. Although the Japanese disaster led to fewer casualties, the destruction is even more vast.

The Japanese have devoted 100,000 troops to helping in the recovery, but they found that to be but a drop in the bucket. About 2 million citizens were stripped of water, electricity, and utilities—twice as many as in Katrina, and as many as in Haiti. The supply chain disintegrated, leaving those in shelters and those sheltering in their homes to depend on the sparse resources deployed by the military. Many are homeless due to the six-story wall of water that washed away their homes with a 150 mph tsunami. Complicating aid efforts are the fears about radiation release from the Fukushima nuclear reactors and the lack of fuel since the refineries along the coast were damaged. Sadly, due to the radiation fears, most medical relief groups, even the US government’s Disaster Medical Assistance Team have not deployed to help. I say “fears” because the dosimeters my team wore show no significant radiation exposure. My hopes are that those interested in going to help may be encouraged by our experience.

We arrived one week after the disaster on an otherwise empty flight. Narita International Airport, though, was jammed with expatriates fleeing the country, many of whom were worried about the nuclear reactors melting down. The roads were limited to emergency transport vehicles, and our bus cost $1,200 per person to get to Ishinomaki.

 Although a lot of aid had reached Sendai, we brought the first physicians, hot food, baby formula, and energy bars to Ishinomaki. It was still very cold, and many illnesses we saw were due to crowding in the shelters as folks tried to sleep close together, conserving heat because kerosene was in short supply. The famously civil Japanese kept the peace in shelters, but survivors privately shared their frustration that blankets were inequitably distributed, leaving many shivering.

Due to the crowding, we were surprised to see that pneumonia and gastroenteritis also predominated in Ishinomaki, just as was common in Haiti. There wasn’t cholera in Japan, but many symptoms reminded us of Haiti and Hurricane Katrina, such as conjunctivitis, pharyngitis, and bronchitis due to irritation from the dust from rubble and silt left by receding floodwaters. The close quarters in shelters provided the opportunity for respiratory particles to get past face masks that were soaked with moisture from breathing. Only dry masks filter out infective organisms; when masks are wet, air seeps in around the edge of the mask. The typical fastidious cleanliness of the Japanese people was limited by the lack of running water. Diarrhea was spreading. Our teams were surprised by the odor of urine in shelters. Then we realized that the elderly, toddlers, and infants hadn’t bathed in a week and didn’t have a change of clothes. Some were incontinent of urine (which fortunately is sterile), but also with stool. Alcohol hand rub was in high demand, but no water was available to rinse the residue that accumulates after 20 applications.

Helping out in Japan is much easier in some ways than it was for past disasters, and in other ways it is more difficult in others. The Japanese are rightfully very proud of their excellent preparations for disasters, and the relative low death rate given the magnitude of the earthquake and the resulting tsunami speaks to the success of executing on those plans. It was heartening to hear stories from many survivors who shared how they followed their disaster plan and made it to higher land. It has compelled me to make a plan with my own family. It was heartbreaking to hear how many who followed the plan still died. That waters were so high that many who evacuated to elevated tsunami shelters still drowned.

As we cared for patients, we could ask for transport for sicker patients to get to the just-set-up Red Cross Ishinomaki Hospital. It’s great that the hospital is coordinating volunteer physicians and nurses to care for shelter residents. What is difficult is that, unlike in Haiti, where we were welcomed, shelter after shelter in Japan was unwilling to let us care for survivors. This was true despite the fact that we carried with us a letter from an Ishinomaki city council member asking the shelters to allow us to help. It wasn’t due to regulatory issues of credentialing; our physician was given permission to treat, just as was the case during Katrina. It wasn’t that patients didn’t need care—many were suffering from respiratory illnesses and exposure. It was more about the cultural reticence of seeing a foreign physician using a translator. We will soon return with Japanese-speaking physicians, but it speaks to the difficulty of the Japanese people to accept help, even when in great need.

Another difficulty is trying to get resources shipped to the disaster. We have been working to get two shipping containers full of medical supplies, new Gymboree children’s clothes, and EO Products hand sanitizer to Ishinomaki. We mobilized the shipment but it will take three weeks to get there. The shelter manager called and they recently got a big shipment and don’t have room for more. As I write, I’m scrambling to find another shelter to accept the shipment. This is the reality of relief work halfway around the world. Things change fast, and it makes it difficult to help. The delay in shipping was due to getting the customs clearance to import it duty-free, with the proper documentation from politicians we met while we were there in Ishinomaki. Needless to say, the donor is frustrated about the destination being up in the air, and I’m working my contacts with missionaries that have been distributing goods in nearby Sendai.

One commonality to these disasters was that we arrived a week after the disaster and although the cellular voice networks were often overwhelmed, we could text and access the internet on mobile phones. With the rapid changes from day to day in the disaster, it was helpful to review websites that listed the latest news. In disaster response parlance, it’s called “situational awareness.” It helped us email to coordinate with those at the shelters in terms of what the biggest needs were and where we could help. In Japan, XCom Global donated MiFi devices that gave up to five users the ability to share a Wi-Fi connection. It was a way we could upload photos and videos live to our Facebook and Twitter feeds to let our supporters know what we were up to. Taking this lesson home, I’ve suggested that my employer, a large clinic of a thousand physicians, create a disaster situation website and add mobile phone numbers to my clinic’s disaster preparation plans. That way, we can give updates via a website and do SMS blasts to give updates to all employees. Alternatively, we can text to ask for particular specialists to come help. Right after a disaster, the voice cellular networks are overwhelmed, but texts can get through.

One frustrating thing in a disaster is that survivors often tell you, for example, that they take the red pill for hypertension and a rainbow of other colored pills for a plethora of illnesses. At Palo Alto Medical Foundation (PAMF), I work in a multi-specialty environment where I can refer to the past medical history in an EpiCare electronic medical record (EMR). During Hurricane Katrina and in Haiti, we could also use mobile internet to access and store electronic medical records. During Katrina, the U.S. government aggregated electronic pharmacy records and allowed credentialed disaster relief physicians like my father and I to look up recent prescriptions of survivors online. In Haiti, we received a generous grant from Epocrates in order to do so with their iChart EMR on iPhones.

We helped Harvard develop new disaster relief EMR standards for the WHO last year. One difficulty in the Japanese medical system is that most health care professionals operate in small clinics with systems that are not integrated into larger data networks. There is no way to find out what medications Japanese survivors are taking. Here in the US, our government has incentivized physicians to adopt EMR via $64,000 in HITECH incentive payments over the next four years. In year four, there is a requirement for the EMR to be tied to Health Information Exchanges that create a repository of your health information across multiple providers of care. Four years from now, patients’ health information will be much safer in a disaster or even in less severe trips to the emergency room since physicians will be able to look up patients’ records online. In year two, giving patients access to these records via a Personal Health Record is incentivized. At PAMF, we have done that for a decade via our My- Health online portal. Just last month, we were the first in California to launch access via an iPhone app. My personal experience is that it’s a much more usable way to have electronic visits with my doctor wherever I am using my cell phone and review my records without being tied down to my desktop computer.

You may wonder how we operated these devices while in disasters where the electrical grids are down. We had solar power thanks to donations from We CareSolar, which builds battery-filled suitcases powered by donated Everbright Solar panels, a local manufacturer. This helps charge our headlamps so we can look down throats and see in the dark, and it allows us to recharge our cell phones and laptops. Portable solar lights donated by OneMillionLights were distributed in Haiti last year, and now to Japan. These lights miraculously provide eight hours of light so we can see at night. There is still sun in places where nuclear reactors melt down and leave millions without power.

I'm excited to go to Japan and organize more trips of friends willing to help survivors. If you’re interested in following our progress, you can “like” us on Facebook and read about how our first trip went. You can donate to our efforts using 

or by mailing your tax deductible donation to “Jordan International Aid” at 12860 Llagas Ave, San Martin, CA 95046.

E-mail me if you’re interested in going to Japan or Haiti: 

. Come join us in helping a country even more prepared that us recover from their “perfect storm.” Help them more fully celebrate their season of Sakura.

Articles

Enoch Choi, MD, writes about his experiences leading a disaster relief team in Japan.

After the Tsunami, Physician Volunteers Find Obstacles Both Obvious and Unexpected

	We live in an age in which patients have powerful tools for finding out more about their physicians. In the same way that friends now share online opinions about their favorite restaurants, the usual word-of-mouth recommendations about physicians has extended to online forums. Many physicians find this perturbing and go to great lengths in a futile effort to suppress these online opinions. Some even resort to litigation to remove negative opinions posted on websites and blogs, claiming that they’re libelous. I know many physicians who are struggling with the need to promote their practice while hiding online details about their private lives. Some physician friends of mine are even concerned about their physical safety, as they’ve attracted the attention of patients who have gone beyond being merely fans. These patients have devolved into stalkers that comb the Internet in the hopes of finding a nugget of information that can assist them in their obsession to connect with the object of their desire.

For every reader who is experiencing a similar nightmare or who is worried that they too might become the object

	I’d like to pass along some secrets that these physician friends of mine shared with me. I’ll explain how their “suitors” found out about them, how they fought further inadvertent disclosure, and

	how they have successfully continued an online private life with their loved ones. (To be clear, in this article, I am not referring to my own experience, to the experience of any of my professional partners, or to my place of employment, past or current.)

One barrier to online privacy is that the practice of medicine is by necessity a public endeavor, since you have to let patients know when they can come to see you and list hours of operation on your practice website. Like many urgent care physicians, I don’t keep regular hours, so it’s harder to track me down, but most physicians have a regular schedule that establishes a pattern that’s easy to follow. Because of that, if they are leaving after dark at night, many of my friends ask for a security escort to their vehicle. It’s sad, but physicians are public servants and prime targets for stalkers. I’ve even heard of extreme cases in which the stalker hid inside the office, waiting for an opportunity when the physician was alone. Thank goodness none of my friends have been injured, and I hope it never gets to that. One measure of prevention is to not tempt stalkers by feeding their appetite with online details about your family and friends. 

There is no privacy on the Internet. You need to be aware that anything you write online is public information. Even if you believe that you’re writing on a private website, there are many people who manage that site that have access to your writing. Lapses in online security have disclosed plenty of information to the public that was never intended to be on the open Internet. Even medical records, intended to be secured in private research databases, have been inadvertently exposed. You may feel safer by writing under a pseudonym, but the computer from which you write has a unique address, an “IP address,” that records the location and specific computer from where you’re writing. Even if you write from an Internet cafe, details of what you write can be used to triangulate your identity. 

There are many unexpected ways in which folks can find out about you. Do three different Google searches: one on your name with “Dr” or “MD,” one on your home address, and one on your personal phone number, and you’ll be shocked at where these details can be found online. For references that list my home address and personal phone numbers, I e-mail the administrators of those Web pages and ask them to delete my personal information. You often find the e-mail address of the administrator at the bottom of the webpage. When Googling, don’t stop at the first page of search results, keep going through all of the pages just to make sure. Although you can’t help having your state license registration on a public page, hopefully the only other details on that page are your practice address and contact information. The same goes if you’ve registered your business with your local Chamber of Commerce; make sure their website only provides information about your practice, not your personal details.

When searching, you may also find references and information dating back to medical school and residency. Using these dates, stalkers can approximate your age, so some of my friends have argued in favor of removing dates of med school graduation from public webpages. More recent search results may link to your house sale or purchase, or renovations listed by the local paper, uncomfortably disclosing your home address. If you have given any PowerPoint CME presentations at grand rounds or to trainees, you often put your contact information and e-mail address on the last slide, which will appear online if uploaded for medical residents to review later. You may have published articles in journals whose abstracts appear online and often include your e-mail address—make sure it’s your professional e-mail address. If you have registered your practice’s website URL, the Who.is website (

) shows the address and phone number of the person who registered that URL, which in small practices is often handled by the doctor. Some physicians put their contact information and e-mail in the comments sections of blogs and forums in order to hear back from their favorite physician bloggers, musical artists, or performing arts groups. Guess what? Those details are searchable online. Even if the comment is made in a supposedly private website like Sermo (

), it’s easy to find the necessary information to register (medical school and year of graduation) and read your comments. 

How can putting more public information online help protect your private information? 

One unfortunate place that your home address has to be listed is your local City Hall. If your stalker is determined enough, they can go digging for the record of the purchase of your home since it is a matter of public record. Some physician friends of mine have been concerned enough to purchase their homes through trusts or use the name of their spouse to limit the chance that their home address could be ascertained. But even that might not be enough; I’ve known physicians who had to get restraining orders against particularly persistent stalkers. 

	sure is to flood the Web with information you want your patients to know about you: your professional practice information listed on your clinic’s website, your philanthropic interests, and your community affiliations. There are two ways to increase the visibility of this information and make it come up higher in online searches. One is to submit the links to whatever sites you use

	to promote your practice, such as the local newspaper, online directories by Google and Yahoo, your IPA, county medical society, or even Yelp. You’ll find these by doing a search on your name, and they should already come up early in searches. Increase the page rank (popularity) of your own site by encouraging more sites to link to it. Whenever you do a local talk, use your practice website as the contact information, and they may thank you online by posting a link to your website. You should always link to your practice website when you leave comments on blogs and other websites. If you write in support of particular philanthropies or community organizations, link to your practice website within the article or endorsement. Consider giving health education talks, and in the ad promoting your talk, link to your practice website. Consider answering health education questions in your local paper; they’ll usually post it online, where you can ask them to link to your practice website. You can do the same at sites like MedHelp.org (

), where I answer questions as well. Post many answers, and that will quickly flood search results with the contact information you want people to know, as well as provide more links back to your site to increase page rank and thus searchability. 

One uniform response I’ve had from physician friends who have been stalked is anger and an unwillingness to give up their social life online. They still want to share their lives digitally with family and friends. There are a few ways to make things a little more private, other than flooding the public Internet with what you want the public to know about you. For starters, stop writing about your private life on public webpages; consider just e-mailing friends directly. Many people find e-mailing less useful than updating Facebook when trying to keep family and friends up-to-date, but are worried about inadvertent exposure. Go here 

 to learn more about Facebook privacy settings. I’ve set all of the privacy settings to make my information available to only those I friend request. I can also block specific users, a feature that’s been helpful for friends who have been stalked. Some of them have had to ask Facebook multiple times to intervene to block the many different user IDs that a persistent stalker may set up to try to “friend” them, but it stops after they remove their profile from “Public Search Results”. You may also want to remove your name from any “tags” of photos posted online by friends and family to limit more widespread exposure of your facial image. For my practice, I have a public Facebook page that is viewable to those who are not even signed into Facebook and that serves to redirect search results on my name to this public page. If you twitter about your private life, consider making your tweets “protected” 

 so that only friends you’ve granted access to can read your tweets.

Efforts at maintaining online connections are worthwhile given the power these tools have to deepen our friendships with those we care about. It’s important though that you realize just who you’re keeping up to date with and prevent prying eyes from seeing your private life. With a little care when sharing information online, and a lot of effort at increasing the popularity of your public practice site, you can do it! 

 editorial board member and full-time family physician practicing urgent care as a partner at Palo Alto Medical Foundation, where he sees patients in clinic, as well as online via PHR.

Although the adage that there is no privacy on the Internet is truer than ever, there are several steps that physicians can take to protect their private lives and information while still remaining active online.

The Patient Will See You Now 

We live in an age in which patients have powerful tools for finding out more about their physicians. In the same way that friends now share online opinions about their favorite restaurants, the usual word-of-mouth recommendations about physicians has extended to online forums. Many physicians find this perturbing and go to great lengths in a futile effort to suppress these online opinions. Some even resort to litigation to remove negative opinions posted on websites and blogs, claiming that they’re libelous. I know many physicians who are struggling with the need to promote their practice while hiding online details about their private lives. Some physician friends of mine are even concerned about their physical safety, as they’ve attracted the attention of patients who have gone beyond being merely fans. These patients have devolved into stalkers that comb the Internet in the hopes of finding a nugget of information that can assist them in their obsession to connect with the object of their desire.

For every reader who is experiencing a similar nightmare or who is worried that they too might become the object of an obsessive patient’s attentions, I’d like to pass along some secrets that these physician friends of mine shared with me. I’ll explain how their “suitors” found out about them, how they fought further inadvertent disclosure, and how they have successfully continued an online private life with their loved ones. (To be clear, in this article, I am not referring to my own experience, to the experience of any of my professional partners, or to my place of employment, past or current.)

One struggle is that the practice of medicine is by necessity a public endeavor, since you have to let patients know when they can come to see you and list hours of operation on your practice website. Like many urgent care physicians, I don’t keep regular hours, so it’s harder to track me down, but most physicians have a regular schedule that establishes a pattern that’s easy to follow. Because of that, if they are leaving after dark at night, many of my friends ask for a security escort to their vehicle. It’s sad, but physicians are public servants and prime targets for stalkers. I’ve even heard of extreme cases in which the stalker hid inside the office, waiting for an opportunity when the physician was alone. Thank goodness none of my friends have been injured, and I hope it never gets to that. One measure of prevention is to not tempt stalkers by feeding their appetite with online details about your family and friends.

There is no privacy on the Internet. You need to be aware that anything you write online is public information. Even if you believe that you’re writing on a private website, there are many people who manage that site that have access to your writing. Unplanned lapses in online security have disclosed many writings to the public that were never intended to be on the open Internet. Even medical records, intended to be secured in private research databases, have been inadvertently exposed. You may feel safer by writing under a pseudonym, but the computer from which you write has a unique address, an “IP address,” that records the location and specific computer from where you’re writing. Even if you write from an Internet cafe, details of what you write can be used to triangulate your identity.

There are many unexpected ways in which folks can find out about you. Do three different Google searches: one on your name with “Dr” or “MD,” one on your home address, and one on your personal phone number, and you’ll be shocked at where these details can be found online. For references that list my home address and personal phone numbers, I e-mail the administrators of those Web pages and ask them to delete my personal information. You often find the e-mail address of the administrator at the bottom of the webpage.

When Googling, don’t stop at the first page of search results, keep going through all of the pages just to make sure. Although you can’t help having your state license registration on a public page, hopefully the only other details on that page are your practice address and contact information. The same goes if you’ve registered your business with your local Chamber of Commerce; make sure their website only provides information about your practice, not your personal details.

When searching, you may also find references and information dating back to medical school and residency. Using these dates, stalkers can approximate your age, so some of my friends have argued in favor of removing dates of med school graduation from public webpages. More recent search results may link to your house sale or purchase, or renovations listed by the local paper, uncomfortably disclosing your home address. If you have given any PowerPoint CME presentations at grand rounds or to trainees, you often put your contact information and e-mail address on the last slide, which will appear online if uploaded for medical residents to review later. You may have published articles in journals whose abstracts appear online and often include your e-mail address -- make sure it’s your professional e-mail address.

If you have registered your practice’s website URL, 

 shows the address and phone number of the person who registered that URL, which in small practices is often handled by the doctor. Some physicians put their contact information and e-mail in the comments sections of blogs and forums in order to hear back from their favorite physician bloggers, musical artists, or performing arts groups. Guess what? Those details are searchable online. Even if the comment is made in a supposedly private website like 

, it’s easy to find the necessary information to register (medical school and year of graduation) and read your comments.

How can putting more public information online help protect your private information?

One unfortunate place that your home address has to be listed is your local City Hall. If your stalker is determined enough, they can go digging for the record of the purchase of your home since it is a matter of public record. Some physician friends have been concerned enough to purchase their homes through trusts or use the name of their spouse to limit the chance that their home address could be ascertained. When friends of mine have had stalkers who were that persistent, it had unfortunately gotten to the point where sometimes they needed to go to court to get a restraining order.

The best way to combat inadvertent exposure is to flood the Web with information you want your patients to know about you: your professional practice information listed on your clinic’s website, your philanthropic interests, and your community affiliations. To increase the visibility of this information, there are two ways to make them come up higher in online searches. One is to submit the links to whatever sites you use to promote your practice, such as the local newspaper, online directories by Google and Yahoo, your IPA, county medical society, or even Yelp. You’ll find these by doing a search on your name, and they should already come up early in searches. Increase the page rank (popularity) of your own site by having more sites link to your practice website.

Whenever you do a local talk, use your practice website as the contact information, and they may thank you online by posting a link to your website. You should always link to your practice website when you leave comments on blogs and other websites. If you write in support of particular philanthropies or community organizations, link to your practice website within the article or endorsement. Consider giving health education talks, and in the ad promoting your talk, link to your practice website. Consider answering health education questions in your local paper and they’ll usually post it online, where you can ask them to link to your practice website. You can do the same at sites like 

, where I answer questions as well. Post many answers and that will quickly flood search results with the contact information you want people to know, as well as provide more links back to your site to increase page rank and thus searchability. 

One uniform response I’ve had from physician friends who have been stalked is anger and an unwillingness to give up their social life online. They still want to share their lives digitally with family and friends. There are a few ways to make things a little more private, other than flooding the public Internet with what you want the public to know about you. For starters, stop writing about your private life on public webpages; consider just e-mailing friends directly. Many people find e-mailing less useful than updating Facebook when trying to keep family and friends up-to-date, but are worried about inadvertent exposure. 

You can make your Facebook profile private

. I’ve set all of the privacy settings to make my information private to only those I friend request.

I can also block specific users, a feature that’s been helpful for friends who have been stalked. Some of them have had to ask Facebook multiple times to intervene to block the many different user IDs that a persistent stalker may set up to try to “friend” them, but it stops after they remove their profile from “Public Search Results” and 

make “only friends” able to see “Facebook Search Results."

 You may also want to remove your name from any “tags” of photos where your friends have identified you to limit more widespread exposure of your facial image. For my practice, I have a public Facebook page that is viewable to those who are not even signed into Facebook and that serves to redirect search results on my name to this public page. If you twitter about your private life, consider making your tweets 

Efforts at maintaining online connections are worthwhile given the power these tools have to deepen our friendships with those we care about. It’s important though that you realize just who you’re keeping up to date with and prevent prying eyes from seeing your private life. With a little care when sharing information online, and a lot of effort at increasing the popularity of your public practice site, you can do it!

Enoch Choi, MD, is an MDNG editorial board member and full-time family physician practicing urgent care as a partner at Palo Alto Medical Foundation in CA, where he sees patients in clinic, as well as online via PHR.