Your patients are online. You are online. How many of these scenarios ring true?

• “I did an internet search, and I think I may have dengue fever.”
• “Did you see that Facebook post on that crazy case last night in the emergency department?”
• “I saw that Yelp review about you. Ouch.”
• “How did that patient get my personal email?”

The internet can be a great tool, but it can also complicate our practice and have far-reaching consequences if we aren’t careful with the information we share. Here are some tips for managing the internet’s influence on our patient interactions and professional reputations.

First, let’s take a look at how we can best respond to our patients’ online self-education.

Dr. Google

Dealing with patients (or their family members) who come to the emergency department prepared with their own diagnosis based on an internet search can be challenging. Layperson misinterpretation and self-diagnosis can start things off on the wrong foot, especially if it feels like patients have an agenda or think they can replace us with an internet search. If improperly handled, this can immediately introduce distrust into the physician-patient relationship. We need to respond to their questions and theories, but it is crucial to do so without putting them down or alienating them. How can this be achieved?

1. Understand patients’ motivations. Patients who look up information online may actually be interested in learning and want to hear the physician’s thought process. This also gives the physician the opportunity to apply the information to patients’ specific issues.
2. Encourage patients. While this may sound counterintuitive, encourage and congratulate patients for taking an interest in their health. Being receptive toward patients’ own online research may help improve their sense of empowerment. In addition, belittling patients and using sarcasm, while immensely personally gratifying, will not earn you any points or improve your ability to personally connect to patients and their families. Remind patients that most of the information they find online is general in scope and that putting their symptoms, clinical examination, and other information you obtain into an appropriate context and possible diagnosis is the goal.
3. Consider creating your own online expert content. Patients tend to trust information more when content is easy to read, well-organized, and from authors with medical credentials or other signifiers of authority.
4. Refer patients to reliable online resources. If patients are going to head to the internet to self-diagnose, the best thing providers can do is direct them to websites they know give credible medical information. Sites you may consider referring patients to include Mayo Clinic, Centers for Disease Control and Prevention, National Institutes of Health, and the American Academy of Family Physicians.

Next, we’ll talk about how physicians can manage their own internet and social media presences in ways that can improve (and not damage) their careers.

Maintaining Online Professionalism for Physicians

Certainly, the internet and social media can be leveraged for good, improving patient safety and communication and aiding in the dissemination of educational content. Many physicians are now masters of the internet, using social media as a platform to raise awareness of issues in health care and advocate for patients. Others use it to effectively promote their medical practices.

However, improper or naive use of social media can also result in unintended consequences. Avoiding misuse may help physicians circumvent potential personal, professional, or even legal consequences that could unintentionally result.

Here are some facets to consider.

1. Utilize ethical principles. Physicians should consistently be ethical when preserving the patient-physician relationship. This includes ensuring confidentiality, privacy, and respect for persons in online settings and communications. The pervasive social media craze sometimes carries people to the extreme, resulting in “crossing the line”—both in terms of good taste and confidentiality. First and foremost, do not disclose protected health information (PHI), including any individually identifiable information such as demographic data. Any information or images posted to a social site immediately leave your control, even if subsequently deleted. Once in public, an embarrassing or legally encumbering item can reappear at any (unexpected and unwanted) time.

PHI/HIPAA-protected information includes:

• Names
• All geographical identifiers smaller than a state
• Dates (other than year)
• Patient demographics
• License, device, or vehicle identifiers
• URLs, which can contain identifying information such as names or birthdates
• Internet Protocol (IP) address numbers
• Biometric identifiers
• Full-face photographic images and any comparable images
• Images are a particularly challenging area. Even with meticulous removal of all patient identifiers, patients can put two and two together about a seemingly sterilized posting and recognize themselves or others. In addition to obtaining detailed informed consent to use patient vignettes and images, stay attuned to contextual issues when posting in a public forum. Assume that perception is reality.

2. Separate spheres. It is ideal that physicians keep online professional and social spheres separate. (The American Medical Association strongly recommends this as well.)¹

3. Maintain professional use of email.
Email or any other electronic communications between physicians and patients should only be utilized in an established physician relationship and with patient consent. Documentation of any electronic communication should also be kept in patients’ medical records.

4. Remember the permanency of online activity. Physicians, residents, and students should be aware that online activity can be permanent and that any online activity may have implications for their future professional lives. Employers have turned away job applicants simply due to their problematic digital behaviors.

Managing Your Own Online Profile

One way physicians can avoid dealing with a negative fallout of misinformation is by periodically performing a self-audit to assess the accuracy of online information about themselves. Checking your own online profile can be enlightening. There are a number of consumer-facing sites that provide the public information about you—your education, training, any legal cases, and ratings (eg, Healthgrades, WebMD, Yelp, US News & World Report, etc.).

Negative online reviews can be stressful. Difficult as it sounds, ignoring them is often the correct strategy, as they represent a minority (hopefully) of postings. Realize that the simple act of refuting inaccuracies in patient posts runs the risk of a HIPPA violation. Remember that a posted opinion is just that—an opinion. As hard as it may be, it is better to let the unhappy person vent than to lose sleep or become embroiled in a dispute that might then escalate and become a legal issue.

Final Reminders

1. Be ethical.
2. Keep your professional and personal internet accounts as separate as possible (and always professional).
3. Avoid giving medical advice electronically unless a patient-physician relationship exists.
4. Periodically monitor your online profile.
5. Be aware that anything you post follows you and can affect your future professional life.

Dr. Hughes is an emergency physician in southwest Missouri and northwest Arkansas and a member of the ACEP Well-Being Committee.

Dr. Robertson is assistant professor in the department of emergency medicine at Emory University in Atlanta and a member of the ACEP Well-Being Committee.

Reference

1. Shore R, Halsey J, Shah K, et al. 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.