Use of social media by doctors and medical students is common and growing.
Although professional standards and codes of ethics that govern the behaviour of medical practitioners in Australia and New Zealand do not currently encompass social media, these codes need to evolve, because professional standards continue to apply in this setting.
Inappropriate use of social media can result in harm to patients and the profession, including breaches of confidentiality, defamation of colleagues or employers, and violation of doctor–patient boundaries.
The professional integrity of doctors and medical students can also be damaged through problematic interprofessional online relationships, and unintended exposure of personal information to the public, employers or universities.
Doctors need to exercise extreme care in their use of social media to ensure they maintain professional standards.
The professional standards of doctors and medical students form the cornerstone of quality patient care and are based on expectations of the community and medical peers. The Medical Councils of both Australia and New Zealand have widely accepted guidelines on good medical practice,1,2 and the Australian Medical Association (AMA), New Zealand Medical Association (NZMA) and Australian Medical Students’ Association (AMSA) also have codes of ethics for their members.
The world within which these professional standards apply is expanding rapidly. Society has embraced user-generated content such as blogging, personal websites, and online social media technologies. Research shows that use of social media websites by the medical profession is common and growing:3 in one 2010 study, 220 out of 338 medical students (65%) at the University of Otago, New Zealand had a Facebook account.4
Our perceptions and regulations regarding professional behaviour must evolve to encompass these new forms of media. Recent studies, legal cases and media reports highlight how the inappropriate use of these media can harm patients and the medical practitioners involved.
As part of our commitment to upholding the principles of medical professionalism, the AMA Council of Doctors in Training, NZMA Doctors-in-Training Council, AMSA, and the New Zealand Medical Students’ Association (NZMSA) have created a guide for doctors and medical students that will help them engage in social media while maintaining professional standards; this guide can be found at http://ama.com.au/socialmedia.5 In this article, we present some of the issues explored in the guide.
You are working in a rural hospital, and make a comment on a social networking site about an adverse outcome for one of your patients. You are careful not to name the patient or the hospital. However, you mentioned the name of the hospital in a post last week.
A cousin of the patient involved searches the internet for the hospital’s contact details. In the search results is your posting mentioning the hospital, and your subsequent posting regarding the adverse outcome involving their cousin.
Doctors have an ethical and legal responsibility to maintain their patients’ confidentiality. The accessibility and “indexability” of information posted online poses new issues for the maintenance of confidentiality, as well as for the concept of de-identification. While a single posting on a social networking website may appear to be de-identified, this may be compromised by other postings on the same website. In maintaining confidentiality, it must be ensured that a patient or situation cannot be identified by the sum of the information available online.
Before putting any patient information online, the patient’s express consent should be obtained, and such consent acknowledged within the post. Care must be taken to ensure that the patient is properly de-identified; the use of a pseudonym is not always enough.
Breaching confidentiality erodes the public’s trust in the medical profession, impairing our ability to treat patients effectively. It can also result in complaints to medical registration authorities and employers, involvement of the Australian Information Commissioner (formerly the Privacy Commissioner), or legal action. In Australia, medical boards have already investigated doctors for posting information that could identify patients on social networking sites.6
In September 2008, a junior doctor in the United Kingdom was suspended from work for 6 weeks after describing a senior colleague as a “f***ing s***” on an online social networking forum. Another colleague saw the posting and made a complaint to their employer. The junior doctor apologised for the comments and organised for their removal from the website.7
Professional codes of conduct specify that doctors must not engage in behaviours that can harm the reputation of colleagues or the profession.8 Care should be taken when commenting on any colleague or health organisation in the online environment, even when using the thin layer of anonymity provided by a pseudonym. Acts of defamation may result in loss of employment and civil claims and may put public confidence in the profession at risk.
You get a friend request on a social networking site from someone whose name sounds very familiar. You accept the request. After looking through the person’s profile page, you realise that he is actually one of your former patients. The patient sends you a message to let you know he can’t make his next clinic appointment, but would like to know his results from a histological test you ordered. He adds a cheeky comment about some photos of you on the beach that he saw on the social networking site.
A power imbalance exists between doctors and patients, and the maintenance of clear professional boundaries protects patients from exploitation.8 Doctors who allow public access to their entire online profiles introduce patients to details about their personal lives beyond what the patient would normally discover within the doctor–patient relationship. Further online interaction may constitute a violation of professional boundaries, and serious indiscretions may result in disciplinary action against the doctor. In general, doctors should avoid online relationships with current or former patients. If a patient does make contact with a medical practitioner in an online context, it is appropriate to send a polite message to the patient explaining that further online interaction would be unprofessional.
Another mechanism used by some doctors is to create an online profile used only for professional purposes or to join a professional social networking site; it is possible to pay companies to manage social networking profiles.
Other professional relationships may also become problematic on social networking sites, particularly those with colleagues. Doctors and medical students should think very carefully before allowing colleagues (including employers, other doctors, nurses, allied health professionals, clerks, ancillary staff, students or tutors) access to personal information.
Many people are unaware of how accessible and durable their online information is. Even with the use of stringent privacy settings, once information is posted online, it is “out there”. Information on social networking sites may be made available to third-party companies and internet search engines; even after the contributor removes the content, it will potentially be archived by those third parties and the original host, and may therefore still be accessible. Additionally, individuals may not be able to control all content attributable to them because of the ability of other users to comment on and redistribute online material.
Because of the extensive accessibility of information once it is online, medical practitioners should be very careful about any information that they post, and particularly careful about making offensive comments or jokes, sharing information about unprofessional activities or content produced by others, or joining or creating groups that might be considered derogatory or prejudiced.
Medical students are expected to develop the same professional ethics as doctors. Yet, according to a 2009 United States study, 60% of responding deans of medical schools reported that medical students had posted unprofessional content online, including: violations of patient confidentiality; use of profanity in reference to specific persons or faculties; discriminatory language; depiction of intoxication; sexually suggestive material; and pictures with illicit substance paraphernalia. In many cases this led to disciplinary action by the universities, including dismissals.9
Medical students and doctors alike will always enjoy active social lives; indeed, this is important for wellbeing. However, experiences that were once ephemeral in nature are now being captured and archived by social media technologies, allowing such experiences to be re-examined in the future, when they may be seen in a different light. This has the potential to not only erode the public’s trust in the medical profession, but also to mar the professional reputation of individuals.
Googled yourself? Do you feel comfortable with the results that are shown?
Posted information about a patient or person from your workplace on Facebook?
Added patients as friends on Facebook or MySpace?
Added people from your workplace as friends?
Made a public comment online that could be considered offensive?
Become a member or fan of any group that might be considered racist, sexist, or otherwise derogatory?
Put up photos or videos of yourself online that you wouldn’t want your patients, employers or people from your workplace to see?
Felt that friends have posted information online that may result in negative consequences for them? Did you let them know?
Checked your privacy settings?
While medical students and doctors are entitled to a private personal life, online social media have challenged the concepts of “public” and “private”. Once information is online it is nearly impossible to remove and can quickly spread beyond one’s control. A moment of rashness could have unintended and irreversible consequences in the future — inappropriate online activities can be detrimental to patients, colleagues, your training and employment prospects, and your personal integrity. This is not to say medical professionals should avoid using social media; their use can be personally and professionally beneficial. However, traditional expectations regarding the conduct of the medical profession still apply when using social media, and therefore must be re-examined in the context of such technologies.
Not commissioned; externally peer reviewed.