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Figure. Prevalence of Online Professionalism Violations Reported to State Medical Boards (N = 48)
Figure. Prevalence of Online Professionalism Violations Reported to State Medical Boards (N = 48)

Bar length indicates total frequency for each violation type.

Table. Method of Discovery, Initial Actions, and Disciplinary Outcomes for Violations of Online Professionalism Reported to State Medical Boards
Table. Method of Discovery, Initial Actions, and Disciplinary Outcomes for Violations of Online Professionalism Reported to State Medical Boards
1.
Lagu T, Kaufman EJ, Asch DA, Armstrong K. Content of weblogs written by health professionals.  J Gen Intern Med. 2008;23(10):1642-1646PubMedArticle
2.
Chretien KC, Azar J, Kind T. Physicians on Twitter.  JAMA. 2011;305(6):566-568PubMedArticle
3.
Shore R, Halsey J, Shah K, Crigger BJ, Douglas SP.AMA Council on Ethical and Judicial Affairs (CEJA).  Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media.  J Clin Ethics. 2011;22(2):165-172PubMed
4.
Morrison J, Wickersham P. Physicians disciplined by a state medical board.  JAMA. 1998;279(23):1889-1893PubMedArticle
5.
Greysen SR, Kind T, Chretien KC. Online professionalism and the mirror of social media.  J Gen Intern Med. 2010;25(11):1227-1229PubMedArticle
6.
Lagu T, Greysen SR. Physician, monitor thyself: professionalism and accountability in the use of social media.  J Clin Ethics. 2011;22(2):187-190PubMed
Research Letter
March 21, 2012

Physician Violations of Online Professionalism and Disciplinary Actions: A National Survey of State Medical Boards

Author Affiliations

Author Affiliations: Division of Hospital Medicine, University of California, San Francisco (Dr Greysen) (ryan.greysen@ucsf.edu); Medical Service, Washington DC VA Medical Center, Washington, DC (Dr Chretien); Department of Medical Education, Children's National Medical Center, Washington, DC (Dr Kind); Federation of State Medical Boards, Washington, DC (Dr Young); and Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut (Dr Gross).

JAMA. 2012;307(11):1141-1142. doi:10.1001/jama.2012.330

To the Editor: The use of social media by physicians to post unprofessional content online has been well documented.1,2 While concerns about online professionalism have prompted the creation of guidelines for social media use from professional societies such as the American Medical Association,3 there is no information about oversight by licensing authorities for physician uses of the Internet or disciplinary consequences for violations of online professionalism.

Methods

We surveyed the 68 executive directors of all medical and osteopathic boards in the United States and its territories about violations of online professionalism reported to them and subsequent actions taken. The survey was developed with input from key informants from a representative sample of 10 state boards to determine online actions by physicians most likely to directly affect patients. This study was conducted in partnership with the Federation of State Medical Boards (FSMB) and was approved by the institutional review board at Yale University School of Medicine.

Results

The response rate was 71% (48/68). These 48 boards are responsible for the medical licensure and discipline of 88% of the approximately 850 000 physicians in the FSMB database with an active license in the United States and its territories.

The majority of respondents (44/48; 92% [95% CI, 86%-98%]) indicated that at least 1 of several online professionalism violations had ever been reported to their board (Figure). The most common violations reported were inappropriate patient communication online, eg, sexual misconduct (33/48; 69% [95% CI, 58%-80%] for ≥1 violations); use of the Internet for inappropriate practice, eg, Internet prescribing without an established clinical relationship (30/48; 63% [95% CI, 52%-74%]); and online misrepresentation of credentials (29/48; 60% [95% CI, 48%-72%]). Most boards indicated that incidents had been reported to them by patients or their families (31/48; 65%), although report by other physicians was common as well (24/48; 50%) (Table).

In response to such violations within their jurisdiction, 71% (34/48) of boards held disciplinary proceedings, including formal disciplinary hearings (50%; 24/48) and issuing of consent orders (physician agrees to sanctions without a hearing: 40%; 19/48) (Table). In additional, 40% (19/48) of boards issued informal warnings and 25% (12/48) reported at least 1 instance in which no action was taken. Collectively, serious disciplinary outcomes of license restriction, suspension, or revocation occurred at 56% (27/48) of the boards.

Comment

Most US medical licensing authorities reported incidents of online professionalism violations by physicians, many of which resulted in serious disciplinary actions. While the total number of these actions is relatively small compared with the approximately 65 000 lifetime board actions taken against all licensed physicians currently in the FSMB database, this is likely to change as the use of social media continues to grow. Furthermore, these violations also may be important online manifestations of serious and common violations offline, including substance abuse, sexual misconduct, and abuse of prescription privileges.4 In addition, these incidents are highly problematic in their own right because they reflect poorly on physicians' values to the public.5

Our study has limitations. First, these violations are not currently tracked in the FSMB database and our survey data may be subject to recall bias. Second, we did not match individual violations with specific disciplinary actions or outcomes. In addition, we inquired about lifetime events so we cannot describe yearly incidence or trends over time.

Professionalism is a core competency required for maintenance of licensure and specialty recertification. Regulators and physicians should therefore address emerging online practices. In addition, as state licensing boards monitor physicians for breaches of professionalism, categorizing online professionalism violations separately could be of value to better gauge the extent of this problem. Our findings highlight the need to promote physician understanding and self-monitoring of online professionalism6 and to create consensus-driven, broadly disseminated principles to guide physicians toward high-integrity interactions online.

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Article Information

Author Contributions: Dr Greysen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Greysen, Chretien, Kind, Young, Gross.

Acquisition of data: Greysen, Young.

Analysis and interpretation of data: Greysen, Chretien, Kind, Young.

Drafting of the manuscript: Greysen, Chretien.

Critical revision of the manuscript for important intellectual content: Greysen, Chretien, Kind, Young, Gross.

Statistical analysis: Greysen.

Administrative, technical or material support: Chretien, Young.

Study supervision: Gross.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Gross reported serving as a scientific advisory board member for Fair Health Inc and receiving funding as a collaborator on the Yale University Open Data Access project, which is facilitating objective analysis of Medtronic clinical data. No other author reported disclosures.

Funding/Support: The Robert Wood Johnson Foundation and the Department of Veterans Affairs, as sponsors of the Dr Greysen's fellowship program, helped to fund the research for this study.

Role of the Sponsor: The Robert Wood Johnson Foundation and the Department of Veterans Affairs had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Additional Contributions: We recognize Humayun J. Chaudhry, DO, MS (president and CEO) and David Johnson, MA (vice president of assessment services) at the Federation of State Medical Boards for assisting in the study conceptualization and design, revision of survey instruments, collection and interpretation of data, and writing and revision of the manuscript. We also thank the Robert Wood Johnson Clinical Scholars program and the Department of Veterans Affairs for support of this research and our key informants at state medical and osteopathic boards for invaluable insights into the structure and function of their licensing bodies. Dr Chaudhry and Mr Johnson were not financially compensated for their contributions.

References
1.
Lagu T, Kaufman EJ, Asch DA, Armstrong K. Content of weblogs written by health professionals.  J Gen Intern Med. 2008;23(10):1642-1646PubMedArticle
2.
Chretien KC, Azar J, Kind T. Physicians on Twitter.  JAMA. 2011;305(6):566-568PubMedArticle
3.
Shore R, Halsey J, Shah K, Crigger BJ, Douglas SP.AMA Council on Ethical and Judicial Affairs (CEJA).  Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media.  J Clin Ethics. 2011;22(2):165-172PubMed
4.
Morrison J, Wickersham P. Physicians disciplined by a state medical board.  JAMA. 1998;279(23):1889-1893PubMedArticle
5.
Greysen SR, Kind T, Chretien KC. Online professionalism and the mirror of social media.  J Gen Intern Med. 2010;25(11):1227-1229PubMedArticle
6.
Lagu T, Greysen SR. Physician, monitor thyself: professionalism and accountability in the use of social media.  J Clin Ethics. 2011;22(2):187-190PubMed
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