Affiliations: Berman Institute of Bioethics and Division of General Internal Medicine, The Johns Hopkins University and School of Medicine, Baltimore, Maryland.
Social media use—via Facebook, Twitter, blogs, and other social networking technologies—is widespread in medicine. Surveys consistently demonstrate that physicians (particularly younger ones) and patients frequently use social media personally and professionally.1 Social media's benefits include disaster response efforts,2 public health tool kits (eg, from the Centers for Disease Control and Prevention), and sites where physicians consult each other about patient care. Anecdotal reports of diagnoses aided by social media highlight the potential benefits for geographically remote physicians or obscure diagnoses. Some physicians extol social media's utility in marketing their practices and extending care in an era of time-pressed office visits.
However, social media also present risks to medical professionalism. Media reports include a physician's firing for posting patient information on Facebook and a questionable Twitter conversation about priapism. The academic literature documents infrequent, but notable, unprofessional conduct by physicians and medical students on social media, including privacy breaches, profane language, and discriminatory remarks.3 Realizing the benefits of social media, while minimizing these risks, is therefore a major concern.
The ethical issues arising from social media use in medicine might not be “new.” Similar concerns about privacy, availability, and the physician-patient relationship arose regarding the telephone in the 19th century.4 Nonetheless, the proliferation of social media guidelines promulgated by institutions and professional associations suggests that there is a legitimate need to clarify appropriate use. Unlike e-mail within an established physician-patient relationship, or 1-way communication of health information online, social media involve true online collaboration. Their abridged format, rapid dissemination, and relative permanence underscore their potential impact on the patient-physician relationship and medical professionalism.
Among current guidelines, consensus is emerging around a number of issues, including:
Strict adherence to privacy and confidentiality laws, such as the Health Insurance Portability and Accountability Act (no identifiers or indirect identification via online sleuthing), and to marketing laws, such as Federal Trade Commission regulations;
Maximizing online privacy settings for physicians' personal content and self-monitoring online personae; and
The need for physicians to consider separating personal and professional material online owing to blurred professional and personal boundaries.
Many more issues, however, lack consensus or practical guidance, including the permissibility of:
Posting a patient's information with consent, or when that information is already publicly available ;
Accessing patients' public online material (eg, a psychiatrist agonized over searching a comatose patient's blog for overdose clues)5;
“Friending” patients on Facebook (particularly by primary care providers, who receive more such requests1 and might feel more compelled to accept them because of their longstanding relationships);
Posting anonymously or anonymously as a physician (eg, via the name “anonymousMD”);
Using online information in hiring and firing decisions;
Managing conflicts of interest, as social media complicate “disclosure”; and
Ensuring that social media do not exacerbate health disparities in the “Digital Divide.”
Three fundamental issues of medical professionalism require clarification in the online setting.
While guidelines recommend that physicians separate professional and private identities online, even proponents of “dual citizenship” acknowledge its practical difficulties.6 Online material can be beyond an individual's control and easily traced from personal to professional via sleuthing. Practical worries aside, the mental health effect of maintaining 2 identities is a concern. Determining the line between professional and private identities—or whether one should exist—is critical for clarifying professionalism in social media.
Physicians have always struggled with offering medical advice to friends and family; doing so with innumerable bystanders presents a new challenge. Restricting the “clinical” domain to secure interactions between providers and established patients helps, but addressing the vast remainder of “nonclinical” interactions remains vexing. These interactions include material irrelevant to medicine; medicine-related material beyond one's expertise; material related to a physician's expertise offered to a patient but witnessed by others online; and material related to a physician's expertise but not directed at an individual patient.
Physician misbehaviors offline (eg, inappropriate sexual relationships, conflicts of interest) undeniably reduce trust in the profession; so might online misbehavior. How patients view physicians' involvement in social media; how trust might thereby be affected; or, quite simply, what trust means remain underexamined.7 For example, public reactions to the physicians discussing the patient with priapism on Twitter varied between patently unprofessional to appreciation that physicians similarly struggle with difficult or selfish emotions.
An expanded program of education, practice, and research on social media use in medicine may help clarify these fundamental issues to create more practical, behaviorally oriented professional guidance.8
The generational gap in social media use and the importance of mentorship in developing professional identity highlight a need to expand education in social media at the undergraduate level and beyond. Innovative curricula, not just guidelines, are critical.
Already, physicians on popular blogs tout the patient-related benefits of social media; some even suggest that engagement is an ethical obligation. Interestingly, physician engagement with social media might arise from growing evidence of clinical effectiveness, not just personal use. Bridging the practice divide requires more integration of professionalism at social media conferences and more involvement by advocates and social media users in guideline development.
Most importantly, informing medical education and practice requires expanding research. Accurately documenting social media use is an ongoing need; the existence of early adopters presents opportunities for novel comparative research. Certain facts might quell worries, such as infrequent patient use of physician-rating sites. Others might suggest targeting physician segments for education and professionalism interventions, eg, by focusing “high-use” vs “low-use” physicians. Finally, obtaining a complete picture of social media use will require patient-centered research, including patients' expectations of their physicians, how behaviors online impact trust, and health outcomes and disparities associated with social media use.
In conclusion, professional guidance on appropriate use of social media by physicians is at a critical juncture. Physicians should follow current consensus recommendations on social media use. However, unsettled areas suggest the need for an integrated program on professionalism and social media in medicine.
Correspondence: Dr DeCamp, Berman Institute of Bioethics, The Johns Hopkins University, 1809 Ashland Ave, Baltimore, MD 21205 (email@example.com).
Published Online: August 20, 2012. doi:10.1001/archinternmed.2012.3220
Financial Disclosure: None reported.
Funding/Support: This work was supported by a Greenwall Foundation Fellowship in Bioethics and Health Policy.
Role of the Sponsors: The funder had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
DeCamp M. Social Media and Medical ProfessionalismToward an Expanded Program. Arch Intern Med. 2012;172(18):1418-1419. doi:10.1001/archinternmed.2012.3220