In the United States, patients are losing trust in physicians.¹ To some degree, this shift is reflective of a greater trend of skepticism toward many of our country’s institutions. But in the social media era, tales of “patient beware” may be accentuating this mistrust, posing fresh ethical dilemmas for the modern physician.

Yes, social media platforms—such as Facebook, Twitter, and Instagram—hold enormous potential in communicating health information to the public, fostering professional camaraderie, and disseminating best practices among colleagues in emergency medicine and other specialties, among many other uses. The #FOAMed (free open-access medical education) movement is representative of that potential.

Potential Pitfalls

But with its positives, social media has also created new dangers for physicians, particularly with respect to our standards of professionalism. Studies have suggested that the public holds medical providers to a hgher standard for social media conduct.² Physicians, too, are often not careful about cultivating and curating their online presence. Even in 2012—when both Twitter and Facebook were less than a decade old—Greyson and colleagues published a notable study in JAMA highlighting physician violations of online professionalism that had been reported to  state medical boards.³ At the time, the most common violations included inappropriate patient communications online, the use of the internet for inappropriate practice, and online misrepresentation of credentials. More recently, a practice known as doxxing—the online sharing of information from patients and physicians meant to be private—has become a concern.

The private-public duality physicians carry—medical practitioner in one world, private citizen in the other—can unintentionally merge in the realm of social media. Some physicians may fail to see how online posts could be viewed as inappropriate or offensive from a professional perspective or endanger the public trust toward ourselves, our peers, and our institutions. At the same time, many would argue that physicians should be offered the same right to expression as anyone else.

Social media is also complicating the private-public tension in entrepreneurial endeavors. For example, as one of us wrote in an essay for Slate last year, a growing number of physicians and physician trainees are using social media platforms to build brands for themselves and promote products for compensation, not so different from the thought leaders courted by pharmaceutical companies in previous generations.⁴

How Should the House of Medicine Handle Social Media?

Where should ethical lines be drawn, and by whom? How should those standards be enforced? Ethical guidelines from professional societies on these issues are often vague and inevitably struggle to keep up with the rapid pace of change. The key question is, What can physicians and academic programs do today to ensure that our profession continues to hold the trust of our patients, navigate the ethical challenges of social media, and leverage it in ways that do not negatively impact our standards of professionalism? We propose:

1. Formal training related to social media use and its ethical implications during training and in independent practice should be developed and implemented. Residency programs and medical schools should consider adding curricula that highlight the importance of safeguarding the social capital conferred by the medical degree. Such curricula should include a summary of evolving community standards that should be continuously molded, maintained, and revised by discussion and should involve everyone in medicine’s hierarchy. We should then hold ourselves collectively accountable for executing these standards—whether that means disclosing conflicts of interests when recommending a product on Instagram or discussing academic medicine on Twitter. These curricula should cover both communication between a physician and the public and standards of physician-to-physician communication on social media networks (eg, Doximity, Figure 1, etc). To further expand the reach of these curricula, academic institutions should consider incorporating these discussions into department programming and grand rounds. Talks on this topic ought to raise questions and encourage introspection for the purpose of fostering an evolution of community standards, rather than merely scaring people away from social media use altogether.
2. Encourage physicians to shape their own online presence and practice “dual citizenship” on social media, consciously separating their professional and private lives on digital media, as per Mostaghimi and Crotty.⁵ Physicians and physician trainees should be encouraged to monitor their digital footprint (eg, what may show up in a Google search of their name) regularly. We should also move to take command of that digital footprint, shaping it for ourselves through the creation websites and social media accounts for our professional citizenship, including resources that may benefit our patients. Institutions can offer guidance on the mechanics of that process through hosting workshops for physicians and trainees. Given that our patients hold us to a higher ethical standard on social media, we should also take a cautious approach when posting content on our private accounts and, at the very least, better utilize privacy settings to hide our personal activity on these platforms.
3. Always respect our patients and their information, taking caution when posting or discussing anything about them online. It is generally wise to ask for consent (or sufficiently anonymize) and to pause before using any patient information. If and when we do interact with patients and the public online—whether that be answering questions on Twitter or in an interview shared on a podcast—it should be done in a way that reflects the permanence of digital ink.

As physicians, our relationships with patients and the public are now greatly shaped by social media. This reality presents risks, yes, but also new opportunities to connect with colleagues and patients, and share best practices and enhance mutual trust. If leveraged sensibly, a carefully curated social media presence may ultimately help stem the long tide of down-trending public trust in physicians.

References

1. Khullar D. Do you trust the medical profession? New York Times. 23, 2018. Available at: https://www.nytimes.com/2018/01/23/upshot/do-you-trust-the-medical-profession.html. Accessed June 11, 2019.
2. Jain A, Petty EM, Jaber RM, et al. What is appropriate to post on social media? Ratings from students, faculty members and the public. Med Educ. 2014;48(2):157-169.
3. Greysen SR, Chretien KC, Kind T, et al. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;307(11):1141-1142.
4. Khetpal V. The latest crop of Instagram influencers? Medical students. Slate. Nov. 29, 2018. Available at: https://slate.com/technology/2018/11/medical-students-instagram-influencers-ethics-debate.html. Accessed June 11, 2019.
5. Mostaghimi A, Crotty BH. Professionalism in the digital age. Ann Intern Med. 2011;154(8):560-562.

Mr. Khetpal is a medical student at the Warren Alpert Medical School of Brown University in Providence, Rhode Island.

Dr. Schears is a professor in the department of emergency medicine at the University of Central Florida College of Medicine in Orlando, and chair of the ACEP Ethics Committee.