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Jul 20 2011

Practicing medicine in the Facebook age: Maintaining professionalism online

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In April 2011 a Rhode Island emergency physician was fired by her employer and reprimanded and fined by her state medical board for posting what she thought was anonymous information about a patient on her Facebook page. The NC Medical Board has yet to publicly discipline a physician or other licensee for similar unprofessional behavior. However, the Board has sent at least two private letters of concern to physicians who disclosed information that they obtained during a physician-patient encounter on social media sites. Both licensees indicated to the Board that they considered the information to be anonymous and amusing. In fact, these disclosures were breaches of patient trust.

The informality of social media sites may obscure the serious implications and long term consequences of certain types of postings. Otherwise careful and ethical physicians may inadvertently drift into unprofessional behavior. It is anticipated that the number of disciplinary cases (which usually start with complaints from patients) related to social media will increase as the use of such sites increases among health care professionals. When physicians fail to carefully consider the implications of their online activities, it may be harmful to individual patients, the medical profession and, not least, the physician.

Why is the use of social media a particular concern for health care practitioners? It is not necessarily fair or reasonable, but the fact is, health care practitioners are held to a higher standard than others with respect to social media, as they are in other areas of life. This is because health care professionals, unlike members of the lay public, are bound by ethical and professional obligations that extend well beyond the exam room.

The Board does not currently have a formal position on licensee use of social media. However, the Board believes the physician-patient relationship should be considered sacred. Aspects of the NCMB’s existing position statement on The Physician-Patient Relationship are relevant in the social media context. The position states that any act by a physician that violates patient trust places the physician-patient relationship at risk. In November 2010, the American Medical Association issued a policy on Professionalism in Social Media, signaling rising awareness of potential problems with physician use of these sites.

Let me be clear: The Board recognizes that social media has increasing relevance to professionals and encourages its responsible use. In fact, the NCMB recently established its own Facebook page as a way to get its news and information to a broader audience.

However, physicians and other licensees must understand that the code of conduct that governs their face to face encounters with patients also extends to their online activity. The licensee has a responsibility to maintain professionalism online. This responsibility includes absolute obligations not to disclose or violate patient privacy. In the context of social media, this specifically extends to online posts of anonymous or de-identified information or material acquired while providing patient care.

Even the posting of information for which patient permission has been obtained should be carefully scrutinized for improprieties, or the appearance of improprieties. The unequal relationship between a physician and patient may result in an unappreciated violation of trust. The patient may give consent to online posts that they would not or could not otherwise agree to, out of a sense of obligation to the physician. Another potential area of concern is the practice of posting pictures taken during international medical mission trips. These photos often include patients who have been seriously injured or have unusual conditions. Most ethicists believe it is improper for physicians or other clinicians to display such pictures on social media sites. Recent technological advances, including the use of face-recognition software to identify individuals in posted photos, increases the peril of sharing images of patients online.

The blurring of the line between a physician’s professional identity and private life represent an additional area of hazard. A physician’s publicly available online content directly reflects on his or her professionalism. It is advisable to separate your professional and personal identities online (maintain separate email accounts for personal and professional use; establish a social media presence for professional purposes and one for personal use, etc.) This practice is sometimes referred to as establishing "dual citizenship" online.

Privacy, however, is never absolute and considerations of professionalism should also extend to your personal accounts. Do not use social media to disclose information you would not want your patients or public to know. Posting of material that demonstrates, or appears to demonstrate, behavior that might be considered unprofessional, inappropriate or unethical should be avoided. Would a patient who is dissatisfied with the results of his or her surgery who then finds a picture of their apparently inebriated surgeon on Facebook be more likely to file a malpractice suit? I don’t know, but it is worth thinking about. Venting frustrations through the online use of profanity, disparaging or discriminatory remarks about individual patients or types of patients is unacceptable.

There’s no doubt that online networking encourages personal expression, but health care practitioners would do well to remember that their presence on the Internet makes their personal attitudes and activities infinitely more visible. Public discussions about frustrations and work related activities may reach unintended audiences, causing others to make unfavorable judgments about your professional demeanor. This includes not only patients and colleagues, but prospective employers. Posts you find humorous may be offensive to others.

It’s complicated, to say the least. Although I am a strong proponent and frequent user of information technology, the issues discussed in this article are daunting enough that I have made a personal decision not to use social media.

If you do use social media, now is a good time to examine each post on your various accounts and delete anything that is questionable. Unprofessional material could be defined as any content that might be interpreted as possible evidence of substance abuse, sexism, racism or lack of respect for patients. Be sure to include online organizations, groups or sites that you “like,” follow or participate with in the review of your online social media presence. Many patients search for their physician’s social media presence and may draw unflattering conclusions if they find that their health care provider is associated with groups that have disparaging or derogatory titles or inappropriate pictures. Again, publicly accessible
sites should not contain information you would not disclose to patients directly during a doctor-patient encounter.

One dilemma physicians with a social media presence may encounter is “friend” requests from patients. Unless you maintain a separate site for patient specific information, it's generally not appropriate to include patients as personal, social connections. Health care practitioners must maintain the same boundaries in the online context that they would follow in accordance with established professional ethical guidelines in a more traditional physician-patient setting.

Above all, health care professionals must be sensible of the ubiquitousness and durability of Internet posts. An online indiscretion will have far more widespread and long lasting impact than an unguarded comment to a colleague that is inadvertently overheard. When physicians or other health care practitioners discover posts by colleagues that appear to be unprofessional, they have a responsibility to bring that content to the attention of the persons involved. If appropriate action to remedy the situation—by removing an inappropriate post, for example—is not forthcoming, the matter should be reported to appropriate authorities.

The NCMB is considering whether it should develop a position statement to give formal ethical guidance and to provide a framework of standards of online professionalism.

The Board welcomes your comments on this subject.

Professionalism in the Use of Social Media

The Internet has created the ability for medical students and physicians to communicate and share information quickly and to reach millions of people easily. Participating in social networking and other similar Internet opportunities can support physicians’ personal expression, enable individual physicians to have a professional presence online, foster collegiality and camaraderie within the profession, provide opportunity to widely disseminate public health messages and other health communication. Social networks, blogs, and other forms of communication online also create new challenges to the patient-physician relationship. Physicians should weigh a number of considerations when maintaining a presence online:
  1. Physicians should be cognizant of standards of patient privacy and confidentiality that must be maintained in all environments, including online, and must refrain from posting identifiable patient information online.

  2. When using the Internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute and that once on the Internet, content is likely there permanently. Thus, physicians should routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate.

  3. If they interact with patients on the Internet, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just, as they would in any other context.

  4. To maintain appropriate professional boundaries physicians should consider separating personal and professional content online.

  5. When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.

  6. Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.


There is little research on physician attitudes about social media sites, and how they use them. A recent survey gives some intriguing hints.
  • 40 percent of physicians surveyed have a page on a social networking site such as Facebook or Linked In.

  • 84 percent of physicians disagreed with the statement, “I am willing to connect with my patients on social networking sites, such as becoming “friends” on Facebook.”

  • 43 percent of physicians disagreed that “Patients can learn a lot of helpful information about their health conditions by communicating with other people over the Internet.” 28 percent of physicians said they were “neutral” and 29 percent agreed with the statement.

Source: Markle Foundation, January 2011. Results are based on survey responses from 779 physicians drawn from a national sample that is generally reflective of the U.S. physician population. Younger physicians may be somewhat underrepresented.

''Like' the NCMB on Facebook

The NCMB’s goal is to persuade at least 100 individuals to ‘Like’ its Facebook page by the end of the calendar year. At press time, nearly 60 individuals had ‘Liked’ the Board’s Facebook page.

The NCMB believes its Facebook page is a convenient way for licensees to stay on top of important issues that may affect their practices.

 Comments on this article:

It is also important to note that such issues also extend to the numerous other social networking platforms, including those such as Twitter.  These sites will continue to rapidly grow, and as our patient population becomes more adept at using them to communicate, physicians will surely be asked to maintain a more prominent online presence. 

It should be noted that some physicians who are already active online have a difficult time understanding that professionalism extends to the digital world (Chretien et al. JAMA 2011;305: 566-8.).  As a profession, part of our obligation as members is to hold ourselves to the standards demanded by the public.

Ryan Madanick (Twitter: @RyanMadanickMD)

By Ryan Madanick, MD on Jul 30, 2011 at 12:25am
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