Social media and physicians: A good pair, but guidelines for use needed

In 2004, Kevin Pho, MD, an internist in private practice in Nashua, N.H., launched a blog to discuss breaking medical news. At first, his expectations were low.

Fast forward to 2011. Pho’s blog, KevinMD.com, now averages 310,000 page views per month. It has launched him to superstar status in the realm of physician bloggers. His online presence has expanded to popular social networking sites, including Facebook and Twitter. He is regularly sought out for commentary in national media.

His blog is one example of the current power of social media.

“We needed a way for physicians to offer commentary quickly for patients to know how medical news affects them,” Pho told Infectious Diseases in Children. “Whenever a drug is recalled or there are changes in cancer screening recommendations, for example, I can provide that context on my blog, which can be dynamically updated at the speed of news break.”

In November, the American Medical Association created a policy about professionalism in the use of social media. Its guidelines include: maintaining standards of confidentiality; using privacy settings to safeguard personal information; and maintaining appropriate boundaries of the patient-physician relationship. In addition, the guidelines suggest that physicians bring any perceived unprofessional content on behalf of their colleagues to their attention and, if the colleagues do not take action, to bring the matter to the appropriate authorities. Lastly, the guidelines advise physicians that their actions online may negatively affect their reputations and medical career.

From the Mayo Clinic creating a Center for Social Media to a 2009 Manhattan Research survey revealing that 35% of the US adult population uses social media outlets for health and medical purposes, mounting evidence suggests one certainty: Social media is here to stay.

Empowered patients

Social media has made health care more transparent, Pho said.

“By definition, social media encourages a two-way interaction, so it gives patients a voice. Not only can patients look behind the curtain and see what a physician thinks, but they can also respond to it,” Pho said in an interview. “There is a lot more interaction, and that barrier between the patient and health care provider has come down with the advent of social media.”

In the past, the physician was the sole controller of health information, but with the advent of social media, this role has changed, according to Bryan Vartabedian, MD, a pediatrician at Texas Children’s Hospital. He runs a blog called 33charts.com.

“The biggest thing that social media has done is to empower patients,” Vartabedian said. “For the better part of modern civilization, health information has been under tight control of physicians. With the open access, patients now have unlimited access to information, which puts them in a unique position. The role of the physician is being completely redefined in the face of social media.”

A lot of inaccurate information exists on the Internet, and social media is one way for physicians to provide reputable sources of information to their patients, Pho said. Social media also provides an avenue for patients to give feedback on the physician’s viewpoints.

“Having that guidance on the Internet is tremendously helpful for both the physician and the patient,” Pho said. “If patients don’t like what you have to say, they’re more inclined to say so via social media. Seeing things from a patient’s perspective is definitely illuminating, and it helps me become a better doctor.”

Rob Lamberts, MD, a primary care physician in Augusta, Ga., maintains the blog Musings of a Distractible Mind (distractible.org), through which he talks about many issues, not just medical topics. He told Infectious Diseases in Children that his blog provides a voice that he would otherwise not have in the professional world, where many people, including other physicians such as those in academic medicine, do not understand the issues unique to private practice, where doctors see patients all day, every day. He said his blog has given him incredible chances to state opinions on a scale that he never could have imagined.

“The biggest change is that patients are communicating with people other than their own doctors, including other patients with the same disease or other doctors with various viewpoints. People get a truer perspective of things,” Lamberts said. “The interaction through social media between doctors, patients and nurses across the country and even the world has been a very positive experience.”

Lamberts said he remains unsure of the overall effect social media will have on health care.

“It’s like watching a movie. … You can’t take the perspective of a single blogger,” he said. “You have to be willing to look at it as part of a bigger picture. I don’t think people are doing this as much as they should.”

Online professionalism

Although using social media has many benefits, physicians interviewed by Infectious Diseases in Children said it is important to take many things into account when maintaining an online presence. Remaining professional is crucial to anyone who uses social media for work purposes. Even when using social media as a personal network, rather than a professional tool, there remain high standards of professionalism that everybody should adhere to, especially physicians.

In a 2009 study published in the Journal of the American Medical Association, Chretien and colleagues conducted a survey of medical school deans to investigate whether they believed their school’s medical students posted unprofessional content online. Among the respondents, 60% reported incidents in which medical students did post unprofessional content, including profanity, frankly discriminatory language, depictions of intoxication and sexually suggestive material. Just 38% of the responding schools reported having a policy that covers the posting of such illicit material by students. Among the schools that did not have policies in place, only 11% reported that they were developing such a policy.

“People talk about carbon footprints and how everything you do has an impact environmentally. We want people to think the same way about going online,” Ryan Greysen, MD, MA, a Robert Wood Johnson Foundation Clinical Scholar at Yale University and an author of the JAMA paper, said in an interview. “People should be aware of their digital footprints as well, and how everything they do online has an impact on their professional life. It also has an aggregate effect on the way the world views our profession.”

In a paper in the Journal of General Internal Medicine, Greysen and colleagues posit that social media is much like a mirror that reflects both the negative and positive images of a user, and these images “may prove very important in sizing up not only the credentials, but also the character of professionals.”

The idea of online professionalism is that professionals, including physicians, need to be aware of what they post online, and that their patients and colleagues can view what they post as part of their professional persona, Greysen said. Physicians should be aware that what they do on Facebook and other social networking sites is part of their digital footprint and, thus, part of their online professional persona.

Drawing the line

Vartabedian said about once a month, a patient, either an established patient or a new patient, attempts to reach him via his social media presence for medical advice. However, interacting with patients in this manner via social media is not advised.

“Physicians should not be having direct dialogue with patients in public places, even if it is the patient who initiates the dialogue,” Vartabedian said. “Anything that you would not do in public as a physician is what you should not do on a social media platform.”

So how should physicians handle it when patients contact them via social media? Vartabedian advised that physicians immediately take the dialogue offline by prompting the patient to reach them via telephone. He also suggested that physicians discuss with patients why it is not a good idea to have this type of discussion in a public platform, as many people do not understand the privacy issues surrounding the public forums in social media.

Vartabedian recalled a scenario in which a potential new patient contacted him via Facebook and described a problem with her child. Upon reading the symptoms she described, Vartabedian realized it was a very sick baby. Rather than continue the discussion online, he had the mother call him at the office. She did so, and they got care for the baby.

“This represented a dilemma for me because I do not like to entice these patient interactions in a public space, but here is a case where I did not know what would happen to the baby if I didn’t answer that Facebook message,” Vartabedian said. “As patients and doctors comingle, there are going to be more and more subtle dilemmas like this.”

Pho also advised against giving personal medical advice out on the Web, if not only for malpractice issues, but because you never really know just who the other person is.

Privacy

An especially important factor that physicians must consider when using social media is privacy — specifically that of their patients. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 ensures patients that their health information will remain confidential. But as careful as the physicians may be in their social media realm, it is still possible for health information to be divulged, unintentionally.

“Ironically, the whole issue of anonymous blogging is more dangerous than blogging under your real name, as it makes it seem like you would be freer to share private information,” Lamberts said. “The blogs I’ve read that are the most audacious, and that make me cringe from a privacy standpoint, are not those of the bloggers whose names are out there. They are the bloggers who feel safe behind the guise of anonymity.”

Lamberts compared communication on Facebook and Twitter to elevator talk and discussing patient information where other people can hear, and it may be misunderstood.

“We are taught through all of our training that we have to be careful what we say, especially in public places,” Lamberts said. “Twitter, for example, is a very dangerous place, and although you may not mention a particular patient’s name, there’s always the chance for misunderstanding.”

Vartabedian said physicians may say things on a social media platform that may be HIPAA compliant and not identify a patient by name. However, physicians need to go above and beyond the HIPAA guidelines and probably avoid the discussion of any patient-specific matters via social media.

“If I see a patient with a rare disorder, technically I could discuss the case on Twitter without mentioning the patient’s name,” Vartabedian said. “It may be HIPAA compliant, but ethically, if the mother of my patient saw that I had written about it in a public platform, how would she feel? I think it represents a serious breach in the relationship we share.”

Getting involved

Physicians are encouraged to determine the goal of their social media presence, whether it is promoting their practice, promoting themselves and speakers, or advocating an issue they are passionate about, Vartabedian said. Once that is figured out, the physician needs to define where they want to do it, such as a blog, Facebook and/or Twitter.

“I frequently encourage doctors to make a decision about where they want to live in the social media world,” Vartabedian said. “For me, I live on my blog, which is the hub of my social media existence. Twitter and Facebook are outposts for what I do on my blog. Budgeting the time spent participating in social media activities is also an important piece of advice for doctors who want to get involved.”

Pho spends about 3 hours per day on his blog. He urged other physicians to consider the positives of social media and to also become involved.

“The patient engagement and interaction is a great experience,” Pho said. “There aren’t enough doctors online, and we need more legitimate medical providers to be online to provide better health information than what is already out there.”

Lamberts said he spends about 4 to 6 hours per week blogging.

“One of the great benefits of the medical blog world is the collegiality between people all over the world,” Lamberts said “The Internet is about the communication of ideas. If you know how to use it well, you can certainly use it to your advantage.” – by Emily Shafer

Disclosure: Drs. Pho, Lamberts, Vartabedian, Greysen, Chretien and Gillette have no direct financial interest in any of the products mentioned in this article nor are they paid consultants for any companies mentioned.

For more information:

• Chretien KC. JAMA. 2009;302:1309-1315.
• Greysen SR. J Gen Intern Med. 2010;doi:10.1007/s11606-010-1447-1.

Should medical institutions adopt social media guidelines?

A physician point of view

Many physicians are reluctant to get involved with social media because of potential ethical issues. I do believe there should be guidelines to help physicians because this area of social networking for physicians is so new. Currently, there are no specific guidelines regarding physician’s social media use. While the American Medical Association recently released guidance on this topic, it is rather broad.

From the educational standpoint, it is about raising awareness. Some physicians may not be aware of the permanency of what is published on the Internet, or how anonymity is not truly protective online. These topics should be included in medical school curricula. Recently, we had a discussion at the Association of American Medical Colleges annual meeting to help create consensus of what is professional online. We also recently conducted a focus group of medical students at George Washington University to evaluate what they thought was appropriate to post online and their thoughts about institutions creating guidelines for social media use. The general theme was that it was up for debate in terms of what was inappropriate to put online. Students stated that they did not want formal guidelines and wanted to take responsibility for their own actions as professionals. They were very sensitive to feeling controlled by their institutions, but felt that advice and awareness were helpful, and that including this topic in professionalism curricula was important.

From an institutional perspective, if physicians are posting on social media and identifying themselves with a particular institution, a disclaimer stating that they represent their own view, not the institution’s view, would be prudent. There should also be reminders regarding patient privacy; even posting anonymously about a patient encounter creates the potential to violate HIPAA by disclosing details that enable the patient to be identified in some way. When institutional guidelines are being created, all stakeholders — physicians, patients, institutional representatives — need to be included in deciding how to best use social media responsibly.

Katherine Chretien, MD, is an associate professor of medicine at George Washington University.

A legal point of view

If an institution is planning to enter the realm of social media, it makes sense to have guidelines. However, rules for governing social networking are an evolving topic. Social media is all about transparency and disclosure. It serves as a reminder to look at all of the rules that normally apply, and apply them to social networking as well.

From the legal perspective, employment law and laws that apply to communications and advertising, everyone has to be careful of what is published on the Internet, with no engagement in defamatory communication. Employers must be aware of this if they plan to instruct employees about what they can and cannot do while social networking. For example, are there rules around privacy? Do employees have an expectation of privacy? There need to be rules for personal communication made as an employee on behalf of the employer, as well as the ability of the employer to monitor those types of communications. These rules are typically laid out in employer policies and procedures. Employers should also consider establishing disciplinary guidelines for instances in which an employee makes disparaging remarks about the employer: Is that grounds for disciplinary action? What kind of discipline?

In the advertising context, if an employee plans to post, saying, ‘Come to our hospital/practice because we have the best…’ there should be disclosures that the employee works for the hospital/practice so it is not misleading advertising. Federal Trade Commission rules exist regarding this issue.

Nancy Gillette, JD, is general counsel for the Ohio State Medical Association.