Social Media and Professionalism
What are the ethical issues and risks to professionalism inherent in social media use?
Rule 1. Competence
Rule 13. Communications to the Public
Rule 15. Conflicts of Interest
Rule 17. Confidentiality
Social media refers to the interactions among people in which they create, share, and exchange information and ideas in virtual communities and networks.1 In this Advisory Opinion, we use the term to include email, blogs and micro-blogs (such as Twitter), internet forums (such as doctors.net), content communities (such as YouTube and Flickr), and social networking sites (such as Facebook and LinkedIn). As a blend of technology, social interaction, and information sharing, social media is a new paradigm for society and has created an extraordinary transformation of cultural communication.
It has enabled the sharing of health information that is unprecedented in the medical profession’s long history. Due to the relative expansion of this form of communication, only recently have user-guidelines been published by various state boards of medicine and professional medical associations. These guidelines, however, appear to offer conflicting information for the social media user. The guidelines agree on strict adherence to privacy, the need to maximize one’s personal online privacy settings, and recommendations to separate personal and public personas. However, there is a lack of consensus on several points, including medical information posted by the patients themselves, anonymous physician postings, posting patient information with consent even after a patient posts it publicly, and managing conflicts of interest. 2
Although incomplete or imperfect, published guidelines may be helpful for the user because, lacking precedent for this sort of cultural shift, the medical profession has few role models for physicians regarding appropriate social media behavior. Social media has changed traditional physician-patient communication by decreasing the knowledge gap between physician and patient thus equalizing access to many types of health-related information. For patient-users, it has also changed the sanctity of the confidential physician – patient relationship primarily by patients’ purposeful online sharing of confidential information and the inadvertent online disclosure of confidential information by friends and family. There is also a new term to add to our professional parlance, “medical surveillance,” that describes physician-trolling of patient communications on blogs, web sites, and other platforms to gather information about existing patients or for research purposes.
Ethical concerns related to professionalism and the use of social media include the ophthalmologist’s competence to serve as an online expert, appropriate use of social media in research studies, use of appropriate communication standards, disclosures of relevant conflicts of interests, and adherence to the confidentiality of the physician-patient relationship. All communications with patients, the public, and colleagues, whether via social media or in more traditional frameworks, must adhere to appropriate standards of ethics and professionalism to maintain the public’s trust in the medical profession.
In the face of conflicting guidelines, the following general recommendations for the use of social media, based on the Rules of the Academy’s Code of Ethics, are made to educate the ophthalmologist and to protect patients and the profession. Ultimately, it is the responsibility of the ophthalmologist to act in the best interest of the patient, regardless of what type of communication medium is used.
Rule 1. Competence, the ophthalmologist should be competent by virtue of specific training or experience to act as an online expert and should have a legitimate reason for adding to an ongoing online dialogue. Social media provides a very low bar for declaring yourself an expert, thus a true medical expert should make his or her identify and qualifications known.
Rule 13. Communications to the Public. As in all professional communications to the public, promotions or information provided on social media should be offered in a manner that is not false, deceptive or misleading, including information about the participating ophthalmologist’s skills, training, or experience. Ideally, ophthalmologists should offer evidence-based, scientifically valid information that is 1) useful to the intended audience, 2) understandable to the intended audience, and 3) in an appropriate, shareable format. The ophthalmologist should identify him or herself and his/her institutional or representative affiliations. If a communication via social media results from payment by or on behalf of an ophthalmologist, this must be disclosed unless the nature, format or medium makes it apparent.
Rule 15. Conflict of Interest. A conflict of interest exists when professional judgment concerning the well-being of a patient, or the information provided to a patient population via social media, has a reasonable chance of being influenced by other interests of the provider. In a 2008 study, 31% of physician blogs contained product endorsements lacking disclosure3 and in a 2011-2012 survey, 20% of state medical boards noted failed online disclosures on the part of physicians.4 If an ophthalmologist is compensated in any manner for his/her participation in a social media setting or if a posting contains a relevant product endorsement, the payment and/or the potential conflict of interest should be disclosed as part of the posting. The brevity of social media posts complicates disclosure, thus the ophthalmologist must make a concerted effort to assure appropriate disclosure. Disclosure of a conflict of interest is required in communications to patients, the public, and colleagues.
Rule 17. Confidentiality. Special consideration should be taken when using social media to safeguard confidential health information consistent with the law. As in all public communications, ophthalmologists should refrain from using patient identifiers in order to maintain confidentially and to protect patient privacy. Interestingly, social media has engendered a social willingness to share private health information far beyond the boundaries of traditionally-held norms of confidentiality, which may complicate the physician’s efforts to maintain patient confidences.
The HIPAA Privacy Rule5 allows physicians and other health care entities to rely on “professional ethics and best judgments” when determining whether to disclose confidential information in certain permitted circumstances. However, even if a patient has revealed confidential information about themselves on a social media platform, the ophthalmologist should consider obtaining express permission from the patient before following suit. The federal Office of Civil Rights, which is responsible for HIPAA regulations and enforcement, defines a breach of confidentially under HIPAA as, “… an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information such that the use or disclosure poses a significant risk of financial, reputational, or other harm to the affected individual.”6 There are no restrictions on the use or disclosure of de-identified health information.
When queried directly, ophthalmologists may be tempted to offer online medical advice; however, issues of confidentiality and potential liability complicate this practice. The Ophthalmic Mutual Insurance Company (OMIC) notes that online medical opinions may be considered “direct patient treatment” and recommends that interested ophthalmologists contact risk-management specialists for advice about “properly document(ing) your decision-making process and differential diagnosis, including the use of appropriate disclaimers’, as well as the applicability of state licensing requirements and whether they would be waived “when consultations are not delivered ‘live’”.7
These general recommendations are offered to guide ophthalmologists in the appropriate use of social media and may be used to fill gaps in state medical boards’ published guidelines. Ophthalmologists should adhere to appropriate standards of ethics and professionalism to maintain confidentiality and honesty and the public’s trust in our profession.
The Academy offers the following recommendations for how to be a positive influence in social media settings and to maintain professionalism:
a. Identify yourself and your qualifications
b. Identify why you are offering information and how it is substantiated
c. Be trustworthy, honest, and reliable
d. Provide knowledge and information that is useful and desirable
e. Share appropriately
1 Ahlqvist, T, et al. "Social media road maps: Exploring the futures triggered by social media". VTT Tiedotteita - Valtion Teknillinen Tutkimuskeskus (2454):13, 2008.
2 DeCamp, M. Social Media and Medical Professionalism: Toward an Expanded Program Arch Intern Med. 2012;172(18):1418-1419.
3 Laqu T, et al. Content of weblogs written by health professionals. J Gen Intern Med. 2008 Oct:23(10): 1642-1646.
4 Greyson, SR, et al. Physician Violations of Online Professionalism and Disciplinary Actions: A National Survey of State Medical Boards. JAMA. 2012;307(11):1141-1142
5 Summary of the HIPAA Privacy Rule
6 HIPAA Breach Notification Rule
7 OMIC: Policy Holder Services
“Rule 1. Competence. An ophthalmologist is a physician who is educated and trained to provide medical and surgical care of the eyes and related structures. An ophthalmologist should perform only those procedures in which the ophthalmologist is competent by virtue of specific training or experience or is assisted by one who is. An ophthalmologist must not misrepresent credentials, training, experience, ability or results.”
“Rule 13. Communications to the Public. Communications to the public must be accurate. They must not convey false, untrue, deceptive, or misleading information through statements, testimonials, photographs, graphics or other means. They must not omit material information without which the communications would be deceptive. Communications must not appeal to an individual's anxiety in an excessive or unfair way; and they must not create unjustified expectations of results. If communications refer to benefits or other attributes of ophthalmic procedures that involve significant risks, realistic assessments of their safety and efficacy must also be included, as well as the availability of alternatives and, where necessary to avoid deception, descriptions and/or assessments of the benefits or other attributes of those alternatives. Communications must not misrepresent an ophthalmologist's credentials, training, experience or ability, and must not contain material claims of superiority that cannot be substantiated. If a communication results from payment by an ophthalmologist, this must be disclosed unless the nature, format or medium makes it apparent.”
“Rule 15. Conflict of Interest. A conflict of interest exists when professional judgment concerning the well-being of the patient has a reasonable chance of being influenced by other interests of the provider. Disclosure of a conflict of interest is required in communications to patients, the public, and colleagues.”
“Rule 17. Confidentiality. An ophthalmologist shall respect the confidential physician-patient relationship and safeguard confidential information consistent with the law.”
The HIPAA Privacy Rule, subsection on Research (45 CFR 164.501, 164.508, 164.512(i)) The Privacy Rule both permits important research and, at the same time, encourages patients to participate in research by providing much needed assurances about the privacy of their health information. For specific information visit the FTC’s Office of Civil Rights’ website (https://www.hhs.gov/hipaa/for-professionals/special-topics/research/index.html and/or consult your IRB.
“Principle 1. Ethics in Ophthalmology. Ethics are moral values. An issue of ethics in ophthalmology is resolved by the determination that the best interest of the patient is served.”
“Principle 7. An Ophthalmologist's Responsibility. It is the responsibility of the ophthalmologist to act in the best interest of the patient.”
American Academy of Ophthalmology Advisory Opinions of the Code of Ethics, Communications to the Public, Disclosure of Professionally Related Commercial Interests, Release and Confidentiality of Patient Records.
American Medical Association, Council on Ethical and Judicial Affairs Opinion 9.124 - Professionalism in the Use of Social Media. Issued June 2011 based on the report "Professionalism in the Use of Social Media," adopted November 2010. http://www.ama-assn.org/ama/pub/physician-resources/ medical-ethics/code-medical-ethics/opinion9124.page?
Accessed January 23, 2017.
The Federation of State Medical Boards, Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice, adopted April 28, 2012.
Bosslet, GT, et al. The patient-doctor relationship and online social networks: results of a national survey. J Gen Intern Med. 2011 Oct;26(10):1168-74.
Budd, L. Physician tweet thyself: A guide for integrating social media into medical practice. BCMJ. Jan/Feb 2013; 55(1):38-40.
Chretien KC, Azar J, Kind T. Physicians on Twitter. JAMA. 2011 Feb 9;305(6):566–8.
Collier, R. Professionalism: Social Media Mishaps. CMAJ. 2012 Sept; 184(12).
DeCamp, M. Social Media and Medical Professionalism: Toward an Expanded Program. Arch Intern Med. 2012;172(18):1418-1419.
Farnan JM, Snyder Sulmasy L, Worster BK, et al. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-627.
Greyson, SR, et al. Physician Violations of Online Professionalism and Disciplinary Actions: A National Survey of State Medical Boards. JAMA. 2012;307(11):1141-1142.
Greyson, SR, et al. Online professionalism investigations by state medical boards: first, do no harm. Ann Intern Med. 2013 Jan 15;158(2).
Laqu T, et al. Content of weblogs written by health professionals. J Gen Intern Med. 2008 Oct:23(10): 1642-1646.
McGowan, BS, et al. Understanding the Factors That Influence the Adoption and Meaningful Use of Social Media by Physicians to Share Medical Information. J Med Internet Res. 2012 Sep-Oct; 14(5).
Moorhead, SA, et al. A New Dimension of Health Care: Systematic Review of the Uses, Benefits, and Limitations of Social Media for Health Communication. J Med Internet Res. 2013 April; 15(4).
Mostaghimi A. et al. Professionalism in the Digital Age. Ann Intern Med. 2011; 154(8): 560-562.
Peregrin T. Time to tweet: social networking for surgeons. Bull Am Coll Surg. 2011 Feb;96(2):46–8.
Approved by: Board of Trustees, February 2018
©2018 American Academy of Ophthalmology®