AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. May 2015, Volume 17, Number 5: 441-447.

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Professional Guidelines for Social Media Use: A Starting Point

The American College of Physicians and the Federation of State Medical Boards’ guidelines for online medical professionalism apply existing norms of communication and confidentiality to new settings but will need to be modified in light of technological advances and unanswered questions.

Terry Kind, MD, MPH

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;158:620-627.

In real estate, it’s all about where—location, location, location. In comedy, the key is timing. In social media, it’s about both when and where. The timing and context—the community norms, membership, privacy, and searchability of the platform—of a post will affect how it is perceived, and yet a message can be reposted, shared, and disseminated at any future time in other contexts. It is at once fleeting and permanent. Given this complexity, as well as the relative novelty of social media, it is not surprising that guidelines have been issued regarding the use of social media by those in medicine.

What Should Guidelines Be, and When Should They Appear?

What are guidelines for? When should a given set of guidelines be developed and disseminated? When do we seek, use, ignore, or update guidelines? Guidelines are particularly useful in new or changing areas. If a knowledge or practice gap is identified, we seek guidelines to fill that gap. Guidelines are employed to avoid errors or might be used after an error is made, in remediation or reflection. Effective guidelines often include key questions with discussion rather than proclamations. Proclamations are for policy; they delineate consequences. Guidelines are instead intended to advise, explore, and even mentor [1] the learner through a set of questions and scenarios. Rather than each individual student, trainee, attending physician, or other health care professional going it alone and making mistakes that impact the public trust (even if he or she learns from them), guidelines allow those with experience to inform others’ behavior.

Social media guidelines should be designed to help social media users (or social media contemplators) recognize the types of opportunities and challenges that arise in new and changing online platforms. Guidelines applicable to professional conduct in “offline” in-person settings can also provide a useful model for how we should conduct ourselves online.

The ACP-FSMB Guidelines on Online Medical Professionalism

Following the AMA’s policy on professionalism in the use of social media in 2010 [2], the American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB) together issued guidelines on online medical professionalism in 2013 and explicitly stated that their guidelines are “meant to be a starting point, and they will need to be modified and adapted as technology advances and best practices emerge” [3]. Table 1 reproduces the ACP-FSMB official positions on online medical professionalism and identifies key considerations that arise from them.

Table 1. Online Medical Professionalism: Considerations Raised by the ACP-FSMB Guidelines
Guidelines’ Position—The Starting Point Further Considerations/Questions
1: “Use of online media can bring significant educational benefits to patients and physicians, but may also pose ethical challenges. Maintaining trust in the profession and in patient-physician relationships requires that physicians consistently apply ethical principles for preserving the relationship, confidentiality, privacy, and respect for persons to online settings and communications” [4].
  • What is the intent of the online conversation? How will you use social media for educational benefit? What are other beneficial uses?
  • Will you be able to—and how will you—maintain the public’s trust in the profession?
  • How will you maintain confidentiality?
  • How will you handle emergency/urgent situations?
2: “The boundaries between professional and social spheres can blur online. Physicians should keep the two spheres separate and comport themselves professionally in both” [5].
  • Is professionalism an identity or a persona?
  • How much self-disclosure is the right amount?
  • Is it possible to keep your professional and social selves “separate” online? How is this accomplished offline?
3: “E-mail or other electronic communications should only be used by physicians in an established patient-physician relationship and with patient consent. Documentation about patient care communications should be included in the patient’s medical record” [6].
  • What is your plan for when patients request to connect on social media?
  • What is your plan for when you are asked medical questions online?
4: “Physicians should consider periodically “self-auditing” to assess the accuracy of information available about them on physician-ranking Web sites and other sources online” [7].
  • How do you portray yourself and how are you viewed, online?
  • Is representation of who you are accurate, or have you been misrepresented or misrepresented yourself?
5: “The reach of the Internet and online communications is far and often permanent. Physicians, trainees, and medical students should be aware that online postings may have future implications for their professional lives” [7].
  • For those growing up in a digital age and living their lives online, how will the permanence of your Internet presence impact your career? How can you tip the balance towards a beneficial (rather than harmful) impact?
  • Can you delete “former versions” of your self-representation online, and should you do so?
  • Will we become more accepting of personal growth and change online?

The ACP-FSMB guidelines discuss the ways in which our interactions on social media are not private and remind us that we are not interacting with just one person. Social media is a public forum.

One notably helpful component of the ACP-FSMB guidelines is the recommendation to pause before posting. Trust yourself, but pause before posting to reflect on how best to protect and respect patients, their privacy, and your professional relationships and responsibilities. It is helpful to think of the use of social media as a public speaking arrangement in which everything is recorded and shared.

Social media is not one particular environment or location; there are more and less private settings and more and less individual (one-on-one) conversations. It helps to think about your conduct on social media as occurring in a setting where you are exposed to patients and the public at large—as media. It is the mixed setting of social media that should be acknowledged. Social media is everywhere and anytime, both private and public, both in the present, the past, and indefinitely into the future. That awareness should give you that “professional pre-post” pause moment.

The “starting point” should always be our existing norms of communication, confidentiality, and all the relevant tenets of professionalism, applied to new settings. Consider the following questions. How should you, and how do you, conduct yourself with patients, when you are with them in person? Does this change when you are speaking with them on the phone or by email [8]? How should you, and how do you, conduct yourself when near patients (in a hospital elevator, the cafeteria, the open physician or nurse workstation)? If the answer is “it depends,” then perhaps one set of guidelines is insufficient or cannot capture the nuances. That is why the ACP-FSMB recommendations are only a starting point.

The Evolution of Online Medical Professionalism

These ideas about online medical professionalism are rooted in traditional boundaries, but even those may change over time. For example, I don’t insist that my patients call me Dr. Kind, as many doctors might once have done. My outpatient pediatric colleagues don’t necessarily wear the traditional white coats anymore. Like offline customs, social media conventions will change over time.

We should, however, retain the principles underlying norms of professionalism and apply them to new contexts. Twenty years ago we were cautioned against “excessive self-disclosure,” and this remains useful advice in the present social media era [9]. In accordance with the Association of American Medical Colleges’ (AAMC’s) core “entrustable professional activities” (EPAs) for entering residency [10], physicians should maintain their integrity; compassion; respect for others; responsiveness to patient needs that supersedes self-interest; respect for privacy and autonomy; accountability to patients, society, and the profession; sensitivity to diverse populations; and commitment to ethical principles regarding care, confidentiality, informed consent, and business practices. These should be upheld irrespective of “when” and “where.”

The peer-reviewed literature pertaining to use of social media in medicine began with cautions about potential problems of social media and then recognized opportunities [11-13]. Then came a debate about separating professional and personal identities online [14, 15], which is called for in both the ACP-FMSB [3] and AMA policies [2] but also criticized as either unnecessary or impossible.

Next has been the move to include social media in medical student education (i.e., both teaching about social media and using it in curricular delivery) and to trust trainees to use it properly [16] rather than to limit their access. With competencies in professionalism, ethical conduct, and communication, physicians should be equipped to enter residency entrusted with responsible social media use. Social media is now part of quality improvement initiatives, patient engagement efforts, and the measurement of scholarly impact using “altmetrics” (alternative, nontraditional metrics such as online activity) [17]. We will continue to move forward where best practices take us, careful to ensure that we secure the public’s trust as we move forward in online spaces towards reflection, lifelong learning, and discovery in medicine using social media [18, 19].

Conclusion

Ultimately, we are in a public space when we use social media and, with sharing, the timing of any given post is undefined and indefinite. The reach is far and permanent. We’ll keep the one-on-one, in person, clinical encounters to treat our patients, but we can go on to have an even greater public health and educational impact online. There are many positive social media uses for health care professionals. There are lifelong learning [18] and academic sharing and public health opportunities. It is an invitation to communicate and to share ideas.

As technology advances, social media guidelines will be modified, and yet the underlying principles of professionalism will remain. Best practices will emerge, and outpace the guidelines, but if they are “best” they should maintain—and even enhance—the public’s trust in health care professionals. And in moving beyond the starting point, we note that there is no end to the need for professionalism and doing good; it is perennial.



References

  1. Patel PD, Roberts JL, Miller KH, Ziegler C, Ostapchuk M. The responsible use of online social networking: who should mentor medical students. Teach Learn Med. 2012;24(4):348-354.
  2. American Medical Association. Opinion 9.124 Professionalism in the use of social media. AMA Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/ medical-ethics/code-medical-ethics/opinion9124.page? Accessed January 5, 2015.
  3. 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.
  4. Farnan, Snyder Sulmasy, Worster, et al., 621.
  5. Farnan, Snyder Sulmasy, Worster, et al., 623.
  6. Farnan, Snyder Sulmasy, Worster, et al., 624.
  7. Farnan, Snyder Sulmasy, Worster, et al., 625.
  8. Malka ST, Kessler CS, Abraham J, Emmet TW, Wilbur L. Professional e-mail communication among health care providers: proposing evidence-based guidelines. Acad Med. 2015;90(1):25-29.
  9. Gabbard GO, Nadelson C. Professional boundaries in the physician-patient relationship. JAMA. 1995;273(18):1445-1449.
  10. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency: Curriculum Developers’ Guide. Washington, DC: Association of American Medical Colleges; 2014. http://www.afmrd.org/i4a/doclibrary/ getfile.cfm?doc_id=156. Accessed March 16, 2015.
  11. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA. 2009;302(12):1309-1315.
  12. Kind T, Patel PD, Lie D, Chretien KC. Twelve tips for using social media as a medical educator. Med Teach. 2014;36(4):284-290.
  13. Kind T, Patel PD, Lie D. Opting in to online professionalism: social media and pediatrics. Pediatrics. 2013;132(5):792-795.
  14. DeCamp M, Koenig TW, Chisolm MS. Social media and physicians’ online identity crisis. JAMA. 2013;310(6):581-582.
  15. Crotty BH, Mostaghimi A, Arora VM. Online identities of physicians. JAMA. 2013;310(23):2566-2567.
  16. Kind T. Social media milestones: entrusting trainees to conduct themselves responsibly and professionally. J Grad Med Educ. 2014;6(1):170-171.
  17. Priem J, Groth P, Taraborelli D. The altmetrics collection. PLoS One. 2012;7(11):e48753.
  18. Kind T, Evans Y. Social media and lifelong learning. Int Rev Psychiatry. In press.
  19. Chretien KC, Kind T. Climbing social media in medicine’s hierarchy of needs. Acad Med. 2014;89(10):1318-1320.

Further Reading

Chretien KC, Kind T. Social media and clinical care: ethical, professional, and social implications. Circulation. 2013;127(13):1413-1421.

Cunningham A. Social media and medical professionalism. Med Educ. 2014;48(2):110-112.

General Medical Council. Doctors’ use of social media. March 25, 2013. http://www.gmc-uk.org/ Doctors__use_of_social_media.pdf_51448306.pdf. Accessed January 10, 2015.

Kimball E, Kim J. Virtual boundaries: ethical considerations for use of social media in social work. Soc Work. 2013;58(2):185-188.

Lerner BH. Policing online professionalism: are we too alarmist? JAMA Intern Med. 2013;173(19):1767-1768.

Mostaghimi A, Crotty BH. Professionalism in the digital age. Ann Intern Med. 2011;154(8):560-562.

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):165-172.

Canadian Medical Association. Social media and Canadian physicians: issues and rules of engagement. Ottawa, ON: Canadian Medical Association; 2011. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD12-03.pdf. Accessed January 10, 2015.


Terry Kind, MD, MPH, is assistant dean of clinical education and associate professor of pediatrics at The George Washington University School of Medicine and Health Sciences in Washington, DC. Among her academic areas of interest are professionalism and reflection in medical education. She tweets @Kind4Kids and blogs at www.PediatricCareer.org.

Anonymous Physician Blogging, July 2011

Social (Networking) Justice, July 2011

Social Roles and Semi-Public Spaces on the Internet—The Case of Jason and Emily, July 2011

Jason’s Journal—Thoughts of an Ethically Conflicted Medical Student, July 2011

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.