The Perils and Pitfalls of Social Networks: Back to the Cases

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The Perils and Pitfalls of Social Networks

Consider the following situations:

1. You maintain a personal Facebook account that identifies you by photograph, name, age, and practice status. You use the highest privacy setting. A patient who lives in your neighborhood and whose children go to the same school as yours makes an online request to "friend" you. You Google the patient and find her social contacts and information about her employment and political opinions. How would you respond to her request?
2. You are in private practice and maintain contact with colleagues through online social networks. You notice a recent tweet from a colleague employed by a prominent local hospital asking for advice from psychiatrists about management of an acutely suicidal patient without explicit patient permission. What, if anything, should you do?

These situations raise some key questions. Can physicians, nurses, pharmacists, and other healthcare professionals separate their personal and professional identities online? What are the duties of healthcare providers to maintain the integrity and status of their respective professions when it comes to other clinicians' use of social media?

A Primer for Responsible Social Networking

What Are Social Networks?

Online social networks are locations on the Internet where one can create a personal profile and connect to others to create a personal network, among the most popular of which are Facebook, Twitter,Friendster, and LinkedIn. Other tools that permit interaction and spread of information include blogs, wikis, and file-sharing sites. Examples of some healthcare-seeking sites used by patients include Medhelp and DailyStrength. Physician rating sites such as123people use a meta search engine to categorize findings from publicly available records and sites (such as licensing agencies and property tax records) into information clusters that include email addresses, phone numbers, and social network profiles. The use of such networks and sites has exploded in recent years to include a substantial proportion of patients and practicing clinicians.^[1]

How Do Physicians Use Social Networks?

A recent study of physician use of Twitter examined the self-identified profiles of 260 physician users and reported that 30% posted 20 tweets within 1 day or less.^[2] An analysis found that 3% of tweets were unprofessional; 0.7% violated patient privacy, 0.6% contained profanities, 0.3% included sexually explicit material, and 0.1% included discriminatory statements. The public profiles posted by physicians in this study included their names in 78% of cases, a photograph of themselves in 78%, and a link to a Website in 92% of cases.

A national, randomly stratified survey conducted earlier in 2011 found that 93.5% of medical students, 79.4% of residents, and 41.6% of practicing physicians used online social networks.^[3] Practicing physicians were most likely among the 3 groups to have visited the profile of a patient or their family member (15.5%). However, a sizeable majority of respondents, 68.3%, indicated that interacting socially with patients was unethical. The survey also found that patient-doctor interactions within social networks were typically initiated by patients.

A 2009 survey conducted in France found that 73% of residents and fellows had Facebook profiles, with over 90% displaying real names, birth dates, and personal photographs.^[4] Among the respondents, 85% reported that they would automatically decline a request by a patient to "friend" them and 15% would decide on an individual basis. Moreover, 76% believed that the patient-doctor relationship would be altered by patients having open access to their doctor's Facebook page.

Landman and colleagues reported that 64% of residents and 22% of faculty in surgical specialties at 1 institution had Facebook accounts, of which half were publicly accessible.^[5] A cross-sectional study conducted in New Zealand of 338 recent medical school graduates revealed that 63% had active Facebook accounts. While a majority, 63%, had activated privacy options, among those with publicly available information, 37% revealed the user's sexual orientation, 16% noted religious views, and 43% indicated their relationship status.^[6] Almost equal numbers displayed photographs of themselves using alcohol (46%) as included photographs of themselves demonstrating healthy behaviors (45%).

One university in the United States reported 44.5% of residents and medical students using Facebook, with over three quarters including at least 1 personally identifiable piece of information and only a third availing themselves of privacy settings.^[7] A significant proportion showed potentially unprofessional behaviors (photographs of intoxication, overt sexuality, and foul language). A 2009 survey of deans at US medical schools found that 60% had experienced incidents of students posting unprofessional content and 13% had found violations of patient confidentiality occurring as a result of online postings by students within the past year.

The Downside to Social Media

Among key concerns about medical professionals' use of online social forums is the lack of guaranteed security, with the possibility of unwitting transmission of sensitive materials despite the use of privacy settings. For example, Facebook users may "tag" or label another Facebook user (pictures or text) by name without the knowledge or consent of the individual involved. A blog leaves a permanent imprint on the Internet because most blogs are searchable by date, name, or keywords, and a blog entry from long ago can quickly be accessed.

There is a considerable bioethical literature base concerning sexual, financial, and gift-giving boundaries within the patient-doctor relationship.^[9] Engaging in friendships with patients has not been a customary part of the relationship. Online friendships are particularly problematic because they do not prioritize the therapeutic interest of the patient and are associated with potentially inappropriate clinician self-disclosure, problems that can be magnified to the detriment of the therapeutic relationship in a mental health encounter.^[10]Therapists also note that the healthcare provider may become privy to patient information not intended for them through social media sites, such as patient smoking, alcohol ingestion, or dating behaviors. This information has the potential to change the framework of the therapeutic relationship.^[1]

Searching for information online without the patient's knowledge may itself violate patient autonomy and dignity, infringing on the trust integral to the relationship. On the other hand, patients are now able to Google their providers and gather data that may well include inaccurate or false information. Healthcare professionals have to rethink the presumption of anonymity now that their private lives are within the reach of their patients, subject to intensification through images and other highly personal content. The traditional information asymmetry between provider and patient is likely to be increasingly equalized, with escalating information access by patients.^[11]

Some examples of unintended consequences of online participation in networking sites could include:

1. A patient loses his life insurance because his primary care provider documents information in the medical record about his lifestyle behaviors obtained through his Facebook account.
2. A nurse practitioner is approached for a date by a male patient on a dating site on which she has a profile.
3. A well-known psychiatrist's online venting about "drug-seeking patients" is widely disseminated through a "friend" who shares it with his friends.
4. A surgeon shares concerns about technical errors he made in a case on a physician blog and becomes the subject of a lawsuit from the patient.

Venting or debriefing are strategies informally adopted by health professionals to relieve stress. While conversations in closed hospital settings and in-person, face-to-face remarks are short-lived and lend some protection to practitioners, the content of blogs and social networks do not afford privacy and are presumed to be a permanent record.^[10] Examples of online violations of patient privacy leading to unintended consequences are widely available in the lay press.^[12] A recent particularly shocking example, as reported by The Boston Globe,occurredin April 2011 when an emergency room physician was fired for posting photos of a patient on her Facebook page.

Professional Associations Respond

Recognizing the need for clinicians to debrief/vent in appropriate contexts, the Australian College of Critical Care Nurses recommends discussion of appropriate methods with trainees with the recognition of the absolute permanence of electronic communications.^[14] The organization also recommends that institutions develop and publish clear institutional criteria for dismissible offenses.

The 2011 summer issue of the Journal of Clinical Ethics focused its attention on the American Medical Association's (AMA's) Council on Ethical and Judicial Affairs (CEJA) recent report on social media and the medical profession. The CEJA report was prepared in response to Policy D-478.985, Physicians and Electronic Social Networking, which was a request from the Medical Students Section that asked the AMA to address the issue of online professionalism. The report recognizes that use of social media can provide benefits, such as an online professional presence, and allows collegial support, fostering of positive relationships, and sharing of views in the public health interest. However, the report also urges physicians to honor the social contract expected of them. The underpinning of the recommendations for physician use of social media is derived from the AMA Code of Medical Ethics, which emphasizes that physicians in positions that do not directly involve patient care should not suspend their ethical obligations.^[15]

The 2011 AMA guidelines for the use of social media provide a compass for physicians' online presence. They urge physicians to:

1. Maintain patient confidentiality and privacy in all environments and refrain from posting identifiable patient information online;
2. Use the highest privacy settings in social networking sites to protect personal information;
3. Monitor their own Internet presence to ensure that information posted is accurate and up to date;
4. Maintain appropriate boundaries with patients online;
5. Separate personal and professional content online;
6. Approach colleagues who post inappropriate content and report colleagues who persist in violations to the appropriate authorities if the content is not removed; and
7. Recognize that online content and actions can impact careers and undermine public trust.^[16]

Similar recommendations have been previously endorsed or suggested by others from disciplines that include surgery, psychiatry, internal medicine, and pediatrics.^[1,5,10,17]

Some Practical Strategies to Maintain a Safe Online Presence

A number of practical suggestions for the social networking savvy professional can be found in the multitude of articles on this topic available in the literature. Some include:

1. Conduct periodic Internet searches, akin to credit checking, to correct any online misinformation.^[18]
2. Maintain a healthy skepticism about privacy settings and assume that settings may be changed without notification or that privacy technology may be compromised or breached by hackers.^[9]
3. Recognize that the unintended audience for online postings is exponentially large and online content is permanent.^[5]
4. Avoid engaging in dual relationships with patients (such as "friending" patients on Facebook), which threaten the therapeutic dynamic of the patient-doctor relationship.^[9,11,19,20]
5. Obtain consent for use of all online patient images regardless of whether they are identifiable.^[19] Include disclaimer language with all posts such as:
   All patient/s names and identifiable information have been changed to protect their privacy. Additionally, this content was viewed and approved for online use by the patient/s described or depicted.
6. Involve regulatory agencies such as state boards as needed.

The majority of current expert opinion advises caution in the use of social media, emphasizing that the risks of interacting with patients in online social forums may outweigh potential benefits. In fact, some contend that absolute separation of personal and professional life is virtually impossible and recommend only a professional presence online.