DOI: https://doi.org/10.20529/IJME.2012.083
Increasing numbers of medical practitioners and medical students are using online social and business-related networking websites such as Facebook, Doc2doc and LinkedIn. These rapidly evolving and growing social media have potential to promote public health by providing powerful instruments for communication and education. However, evidence is emerging from studies, legal cases, and media reports that the use of these new technologies is creating several ethical problems for medical practitioners as well as medical students. Improper online activities may harm not only individual reputations and careers, but also the medical profession as a whole, for example by breach of patient confidentiality, defamation of colleagues and employers, undisclosed conflict of interests that bias the medical practitioner’s medical advice, posting of advice/information without an evidence base, and infringement of copyright. We developed a self-evaluation checklist for medical practitioners using social media. The checklist addresses three key elements in the use of social media: personal information and accessibility, connections, and postings. It contains questions specifically formulated to evaluate a medical practitioner’s social media profile, to prevent unintended, improper online activities and to promote professional online behaviour.
The number of people using online social and business-related networking websites such as Facebook, Doc2doc, iBibo, LinkedIn, BharatStudent, and Twitter has been growing over the past decade. Currently, India has more than 56 million Facebook users and this number is growing by 26% every six months (1). This makes India the third biggest Facebook market, behind the USA, with 165 million users, and Brazil, with 57 million users. Also, increasing numbers of medical practitioners and medical students use social networking websites (2). For example, recent studies estimate that more than 90% of medical students use online social media (3). These websites provide medical practitioners with powerful instruments for personal and professional communication and, therefore, may promote public health in different ways. For example, they may offer a platform to discuss medical cases and issues, educate, and communicate with colleagues and patients (4). However, evidence is emerging from studies, legal cases, and media reports that the use of these new technologies poses several ethical problems for medical practitioners (5, 6). The line between professional and social life is often blurred on the Internet, and improper online activities can damage not only an individual medical practitioner’s reputation and career prospects, but also the image of the medical profession as a whole (7). Medical practitioners are often unaware of these potential risks (8).
Most of these negative effects can be prevented if medical practitioners are educated on how to properly use social media (9). Several guidelines have been issued by physicians’ organising and accrediting bodies containing practical and ethical guidance for online activities (2, 5, 6, 8, 10, 11). Of the 132 accredited medical schools in the USA, 128 (97%) have some kind of social media policy in place (12). Recently, the General Medical Council, which regulates medical practice in the UK, opened up its draft guidance on doctors’ use of social media for consultation and the results will be published by the end of 2012 (13). However, despite the rapid increasing knowledge on the negative effects of social media, a comprehensive, practical and complete guideline is so far not available. For example, most of the current guidelines do not address issues related to online relationships with pharmaceutical companies that pose a potential conflict of interest (14). Furthermore, these guidelines do not promote evidence-based postings and appropriate use of copyrights.
The situation is perplexing in India since there are few guidelines available about using social media professionally (15). In September 2011, the Department of Information Technology of the Indian government released a draft framework and guidelines for the use of social media by government organisations (16). Although this document may also be valuable for hospitals and physicians’ organisations, it is not specifically directed towards them.
We developed a social media self-evaluation checklist for medical practitioners based on the current literature regarding the possible problems that social media can provoke. The checklist addresses three key elements in the use of social media: personal information and accessibility, connections, and postings. All these contain specifically formulated questions to evaluate a medical practitioner’s social media profile. This checklist is designed to prevent unintended improper online activities and to actively promote professional online behaviour. Consequently, the checklist will lead to an increased awareness of the potential dangers of the use of social media.
Most social networking websites allow users to have their own “profile”, an online page where they can share personal information, including contact details, study or job, relationship status, sexual orientation, political preferences, personal photographs, and social events visited. Users can change privacy settings in order to control who has access to this page, for example ‘friends’ only. However, a recent survey among residents and medical students at the University of Florida demonstrated that only 37.5% of them make their social media profiles private (17).
Connections
Postings
Medical practitioners using social media should have a clear idea whether their profile is used for professional or personal purposes, because this should determine its content and accessibility. They should be aware of who has access to their profile and who they wish to share their personal information with. A professional profile should be easily accessible, and show little or no information about the user’s personal life. In contrast, a personal profile should be accessible only to people with whom a medical practitioner wishes to share it, “friends” on most sites. To check the accessibility of personal information, the medical practitioner could regularly search her/his name on major search engines on the Internet (18).
The first online impression about a person is based on the front page of their profile. Therefore, a proper profile photo determines how ‘professionally’ one presents oneself. If a medical practitioner shows photos of him/her drinking alcohol, being under the influence of drugs, acting in a daredevil manner or behaving inappropriately, this can harm his/her professional status (19). Furthermore, adding hobbies or interests in music, films or persons that might be considered racist, sexist or otherwise derogatory to individuals or groups should be avoided. Medical practitioners should always consider the fact that patients, colleagues, employers or tutors might do a search for them on the Internet.
Since there is a power imbalance between doctors and patients, doctors should not enter patients’ private lives any more than is necessary. Likewise, they should prevent patients entering their own private lives. However, medical practitioners often make online friendships with patients (20). Excessively friendly or intimate contact with a patient jeopardises objective medical care and is therefore unethical. Moreover, through the social media, the doctor may learn of a patient’s unhealthy behaviour. S/he may see a patient under treatment for liver cirrhosis drinking alcohol, or a patient who denies being a smoker smoking cigarettes. This can negatively affect the doctor-patient relationship and patient care. Therefore, accepting online friend requests from patients is, in general, not advised.
Online connections can compromise objective assessment, especially if there is a difference in status, for example in tutor-student, employer-employee and physician-nurse connections. Such connections may bias the assessment of a superior who then may become too friendly. Or colleagues may be negatively judged based on personal information online.
Medical practitioners should be careful with, and transparent about, any online connections with pharmaceutical marketing representatives. The pharmaceutical industry is increasingly using social media for marketing purposes (21). Doctors have been sent networking requests from pharmaceutical company representatives on social media sites such as LinkedIn (14). These connections can be used for marketing purposes, for example in order to send promotional material, which can affect patients’ care. Accepting such networking requests can potentially damage a medical practitioner’s integrity, and questions can be raised about possible conflicts of interest and commitment, such as biased prescribing habits.
Medical practitioners should be careful about their online postings regarding patients, themselves, colleagues, their employers and healthcare in general. In addition, doctors have the responsibility to evaluate posts placed on their social media profile by others. The Internet often gives users a feeling of invisibility and anonymity, making them less inhibited in their postings. This can lead to comments they would be more reluctant to make in normal life. However, it is important to realise that once postings are placed on the Internet, millions of people can be reached in a matter of seconds and the control of how widely a post is shared is lost. These sites allow one to unknowingly disseminate sensitive content to a large number of people in the network, not just to the intended recipients. Since the advent of social media, there are many examples of medical employees being suspended, fired or even sued after placing inappropriate comments online (22).
Doctors have not only a legal, but also an ethical duty to protect patients’ confidentiality. If patients cannot trust this confidentiality, they may withhold information that is important for the diagnostic and treatment process. Therefore, when discussing a medical case, a doctor should not give away any information that leads to identification of the patient. One must always be aware that ‘the sum of information’– the combination of all posted aspects and symptoms about a patients’ case (especially when rare or unique), together with information about the medical practitioner who posted the information (e.g. hospital, department, work time) on different postings or even websites – makes the patient more identifiable (2, 23).
The cornerstone of every doctor-patient relationship is trust. Unprofessional online postings could damage not only a medical practitioner’s own reputation or career but also patients’ trust in the medical practitioner’s colleagues, employer and healthcare in general. Even postings which a user considers humorous could be misinterpreted and considered offensive or unprofessional. A defamatory post about a colleague when expressing frustrations on a bad day of work could be interpreted as libel (24).
Medical information or advice posted by medical practitioners on social media should be based on high quality, up-to-date evidence and, if necessary, regularly be updated. Medical practitioners may more easily comment on subjects in which they do not have up-to-date knowledge because of the informal ways by which people communicate on the Internet. However, patients expect doctors to always work according to evidence-based medicine. Doctors’ statements, whether made in the hospital or on the Internet, should always be in line with this expectation (25).
Copyright is a form of protection granted by law for original works of authorship (26). However, copyright laws are difficult to maintain on the Internet since different legal regulations apply for different countries, which makes it complicated to create laws that are internationally applicable. Users of social media often illegally upload copyrighted material, such as photos and videos. Medical practitioners have a legal and ethical duty to be aware of the legal status of their uploaded material. Copyrights and sources should always be respected when posting information on the Internet.
To prevent medical online postings from being misused or misunderstood, it may be wise to publish a “disclaimer regarding medical information”. An example of a widely used disclaimer is: “This information is intended as a patient education resource only and should not be used for diagnosing or treating a health problem as it is not a substitute for expert professional care. If you have or suspect you may have a health problem, please consult your healthcare provider. In addition, every effort is made to ensure links to external sites as well as medical information and/or medical animations are current and correct” (27).
The number of medical practitioners and medical students in India using online social networking websites is growing. Although these websites provide powerful instruments for personal and professional communication, doctors are often unaware of the potential risks they expose themselves to when using social media. Improper usage of social media may harm not only individual reputations, but also healthcare in general. It is a matter of urgency to increase knowledge and awareness among medical practitioners of these potential risks and to actively promote professional online behaviour. We believe that for this process, a practical, comprehensive, and up-to-date self-evaluation checklist regarding social network usage by medical practitioners is vital. However, few guidelines about using social media professionally are available in India. We have developed a self-evaluation checklist regarding social network usage by medical practitioners. We recommend that before widespread use of this checklist can be advised, its effectiveness needs to be demonstrated to ensure that it is not merely an extra layer of bureaucracy, but actually contributes to increased professional online behaviour.
Author contributions: All authors contributed equally to this work. Funding: None.
Competing interests: We declare no conflicts of interests.
We gratefully acknowledge the anonymous peer reviewer for his/her comments on the first submission of the manuscript.