Surgeons and social media: Threat to professionalism or an essential part of contemporary surgical practice?

Editor’s note: The subject of this article—whether social media is a threat to surgery or an essential part of contemporary practice—will be debated at this year’s Resident and Associate Society of the American College of Surgeons (RAS-ACS) Symposium on Sunday, October 4, at the 2015 Clinical Congress in Chicago, IL. The Advocacy and Issues Committee of the RAS-ACS sponsors the debate.

Over the last decade, social media has become the preferred method of communicating and exchanging ideas among younger generations.¹ The most popular platforms include Facebook, Instagram, and Twitter; additionally, professional networking sites, such as LinkedIn, Doximity, and ResearchGate, have gained prominence in the business and health care worlds.^2,3 Of the more than 7 billion people on Earth, approximately 3 billion are active Internet users, and more than 2 billion have active social media accounts.⁴ In addition to millennials (individuals born between 1986 and 1997), older generations are avid users of social media. In fact, a recent report noted that approximately 56 percent of online adults ages 65 and older use Facebook.²

Patients increasingly use the Internet and social media to obtain health care information, and many hospitals, medical practices, and health care organizations, including the College, use social networks for marketing initiatives, to announce events, and to provide educational material regarding research and health care topics.^5,6 A recent survey of 2,070 respondents by the ACS indicated that 48 percent of surgeons use LinkedIn, 55 percent use Facebook, and 82 percent regularly access YouTube.⁷ In fact, surgeons increasingly rely on online platforms to access educational material and to connect with colleagues on multiple levels—locally, nationally, and even globally. With the rigorous demands of surgical training limiting the time available for personal interaction, surgical residents also use social media and networking websites to keep in touch with friends and family.³

The ability to disseminate information as well as personal opinions to a global audience provides unprecedented opportunities to share information but, at the same time, poses serious risks to physicians’ careers and personal privacy, as well as to the reputation of our profession in general. How should surgeons respond when they get “friend requests” from patients? Should attending surgeons be online friends with their residents? How much information about their private lives should physicians publicly disclose? Are there official rules that can guide physicians and help them avoid legal trouble?

Social media: An essential communication tool

Surgeons today find their time split between clinical practice, administrative and research pressures, travel for and engagement in professional societies, and family and personal commitments. Fortunately, social media allows for professional engagement during the brief pauses in a busy day’s schedule—waiting for an elevator in the hospital, having a snack in the operating room lounge between cases, and riding the stationary bike at the gym all become opportunities to engage in social media.

Social media also is taking on a greater role at regional and national health care meetings and allows for medical advancement and research to be disseminated in a rapid and accessible manner.⁸ The results from an groundbreaking abstract presented at a conference in Tokyo, Japan, for example, could be tweeted by attendees, re-tweeted by colleagues, and read in a surgeon’s Twitter feed between operative cases.⁶ Before the widespread adoption of smartphone apps, a surgeon in Illinois might have to wait a year to see these results published in a journal. This swift spread of information can help decrease the 17-year health research implementation curve and enable innovative treatments to get to patients sooner.⁹ The use of unique meeting and session-specific hashtags—for example #ACSCC15, the hashtag associated with all of this year’s Clinical Congress tweets—allows surgeons to discuss ideas in real time as they are presented to session attendees.^6,10 A live Twitter feed also can ensure that a question is shared with the moderator, particularly in large sessions with numerous attendees, and it can allow a speaker to provide clarification.

Networking is more easily accomplished and supplemented with tools like Doximity or LinkedIn. A chance meeting in a hallway can be solidified with basic professional information obtained through these sites while also providing a means of communication between participants. These relationships can lead to lasting partnerships or research and clinical collaborations. New collaborators and clinical trial sites can be identified through professional forums such as the ACS Communities or Facebook groups; even local collaborations can be enhanced via social media in a way that is already integrated into established social routines.

Social media platforms can play an important role in the critical assessment of medical literature. Established in 2014, the International General Surgery Journal Club (@igsjc) uses Twitter to facilitate discussions about a selected article over the course of several days.¹¹ By partnering with publishers, articles can be made available outside of paywalls. Geographically isolated surgeons no longer have to travel to participate in scholarly exchange—they only need a mobile phone signal. Furthermore, access to the Internet and social media platforms via mobile devices can be used to demonstrate ongoing professional development, such as participation in continuing medical education activities through platforms such as Medscape, Epocrates, and QuantiaMD.^6,7

The educational benefits of social media extend to current students and trainees. Residents can learn from the wisdom shared by attending surgeons on ACS Communities, and online discussions around practice management may provide a glimpse into aspects of professional development not taught on the wards. Recent topics included tips for contract negotiations, advice on billing and coding, as well as discussions about recognizing and avoiding burnout. Medical students considering a career in surgery can see the inclusive, diverse make-up of practicing surgeons by viewing the Facebook profiles of the more than 11,000 individuals who “like” the ACS page. Trainees also can find resources to enhance their clinical education and improve their academic performance. Residents following @SCOREsurg on Twitter receive “This Week in SCORE (TWIS)” assignments to help keep reading habits comprehensive, which should help them to prepare for clinical care duties as well as the American Board of Surgery In-Training Examination. Medical students and residents can prepare for cases using YouTube video reviews, and preclinical students can use Facebook groups to work through problem-based learning assignments.¹²

The advantages of social media become increasingly apparent as surgeons become more involved in advocacy and health policy work, as well. These platforms provide a fast, direct means of interacting with professional organizations and legislative staff. Social media also has the potential to mobilize a large group of people with little effort when calls to action are needed and to provide a direct route for grassroots communication to legislative offices.

Similar benefits can be extended to patient advocacy and disease-specific groups.¹³ A surgeon who joins a Crohn’s disease-focused Facebook group or follows the Twitter hashtag #CrohnsLife will have a better sense of the daily challenges his or her patients manage. These social media tools may lead to meaningful collaborations, identify patient advocates and champions, and may facilitate financial support for research efforts or programs to enhance patient care.

Social media can be used to communicate directly with patients. A Facebook page can help promote a surgeon’s services and expertise, and a Twitter account using a disease-specific hashtag can help raise the profile of a surgeon among potential new patients. While plastic and reconstructive surgeons have led the way in marketing and branding their services through social media, surgeons in other market-driven fields, such as bariatric surgery, also have used social media to reach patients considering surgery. Participating in research discussions or clinical debates via these platforms can suggest professional expertise to potential patients who may be unfamiliar with peer-reviewed publications. Similarly, patients look for physician reviews on social media in the same way they might look for reviews when evaluating a contractor or a caterer.

Social media is uniquely positioned to enhance a surgeon’s professional life. It can be leveraged for education, collaboration, research dissemination, and patient recruitment. Mobile platforms allow users to engage one another via social media, allowing for communication in small, productive bursts. Social media breaks down geographic and practice setting barriers and makes surgeons more accessible to patients, advocates, and each other.

Social media: A threat to professionalism

On the down side, social media also can erase the boundaries between surgeons’ professional and private lives. As the growth in social networking sites continues, many questions remain regarding how these developments will affect surgeons. The difficult situations that can arise through the use of social media add layers of complexity to traditional ethical issues, and despite social media’s widely touted advantages, many critics believe that social media use by physicians and surgeons can be a precarious endeavor.¹⁴

Frequent posting of unprofessional online content by medical students and residents is an example of questionable use of social media.¹⁵ The variability of unprofessional online commentary found in multiple studies ranges from Health Insurance Portability and Accountability Act (HIPAA) violations and sensationalistic reporting of traumatic patient injuries to anecdotal bragging about episodes of inebriation and descriptions of sexual encounters.^16,17 These lapses in judgment not only undermine generally accepted tenets of professional behavior, but they may create public mistrust of the medical profession. As a result of such activity, medical education administrators have begun advocating for screening of an applicant’s online activity.¹⁸

While the inappropriateness of these public lapses in judgment on social media may seem obvious, part of the challenge regarding appropriate online communication stems from the absence of a widely held standard of professionalism. The presumed anonymity of online posting and social media interactions lowers the threshold for unprofessional behavior, and well-established guidelines on what constitutes appropriate behavior can be hard to find.¹⁷ The barriers that separated a surgeon’s professional life from his or her personal affairs are much more susceptible to breaches. Social media allows for virtually all facets of an individual’s life to be interconnected.

It should not be surprising that, with this paucity of boundaries, interactions between physicians and patients have transcended the former limitations of the physician-patient relationship.¹⁹ One example of this newly available interaction occurs when a patient delivers a “friend request” to his or her physician. Inevitably, the physician is placed in the awkward position of trying to appease a friendly request while guarding against privacy endangerment. Acceptance of a patient’s invitation to formally establish a more social relationship can diminish the professional limitations of an acquaintance, exposing the patient to the online personal life of his or her health care provider. Aside from the challenges this situation may create during office-based consultations, such a relationship also can expose a surgeon to risk if the patient has maladjusted behavioral patterns. Vulnerability to criminal activity of varying degrees is certainly increased—multiple accounts have been published by the lay press involving health care professionals who have been stalked or even assaulted by patients or their associates as a consequence of learning and acting on information easily accessed via social media. Given the personal time and family interests that surgeons sacrifice throughout their training and careers, it seems remarkable that some feel inclined to give even more of themselves through social media.⁶

Patient privacy issues

One of the most significant concerns associated with active physician participation in social media centers on the potential medicolegal breaches involving patient privacy. Chief among them are outright violations of HIPAA—recent literature is replete with examples of patient privacy violations.^16,17 Despite significant advances in patient privacy protection in the decades since HIPAA was implemented, online publishing of sensitive patient information still occurs on social media, particularly Twitter and Facebook. Among surgeons-in-training and medical students, these posts rarely provide patient names and identification numbers directly; however, detailed anecdotes of patient encounters, which can be easily traced, are sometimes shared. The content of these posts range from simple personal reflection concerning a tragic diagnosis to outright ridicule and amusement at a patient’s unfortunate injury or circumstance.¹⁶ Such behavior, facilitated by the obscure professional boundaries characteristic of online forums, is susceptible to serious legal ramifications, as these violations of privacy may lead to prosecution, professional censure, and loss of certification or licensure.

Whether intentional or accidental, these missteps within the realm of social media are widely considered unethical and below the professional standards to which we as surgeons adhere. As LaMar S. McGinnis, Jr., MD, FACS, remarked in his 2009 ACS Presidential Address, the “precepts of professionalism extend beyond the operating room, the clinic, and the hospital, to your family, your peers, and other professional associates, your casual contacts, your community, and wherever you venture.”²⁰ Many surgeons would do well to remember Dr. McGinnis’ advice, especially while logged in to their preferred social media account.

Guidelines and recommendations

In general, common sense is a good guide for how to behave when using social media. Many hospitals and health care organizations have issued official social media guidelines that also act as the basis for legal action if violated, and it behooves physicians to be familiar with these policies for this reason.

American Medical Association (AMA)

The AMA’s Council on Ethical and Judicial Affairs issued a report, Professionalism in the Use of Social Media, extending its comprehensive Code of Medical Ethics to online behavior.^21,22 Important guidelines in this report include the following:

• Be aware of the potential dangers of social media and Internet use, which has the potential to compromise both an individual physician and the medical profession as a whole
• Apply confidentiality, privacy, and professionalism policies and guidelines that pertain to offline behavior and practices to online interactions
• Use the highest privacy settings on all social networking sites, and be aware that these settings do not guarantee absolute privacy
• Monitor online content regarding your identity at regular intervals, which may include verifying the accuracy of contact and other information on professional websites or reviewing images and postings of yourself appearing on social networking sites
• Establish two different personas online—one for professional and one for private interactions
• Notify medical colleagues about potentially unprofessional content online and report it to the appropriate professional organizations if the content is severe or persistent

The Federation of State Medical Boards (FSMB)

The FSMB Special Committee on Ethics and Professionalism has issued comprehensive social media guidelines in its Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice.²³ The positive aspects of social media use in physicians’ private and professional lives are acknowledged in this guide, but it also includes warnings about the potentially severe negative consequences of inappropriate use. In a survey of 48 state medical boards, 92 percent (44) reported online-related issues, with serious disciplinary consequences including license restriction, suspension, or revocation occurring at more than half of the boards (27 of 48 medical boards).²⁴ The FSMB’s guidelines emphasize the following:

• Maintain proper online boundaries between physician and patient, similar to any person-to-person interaction in the hospital or office.
• Avoid any online contact with past or current patients, particularly on social media sites with a largely personal focus, such as Facebook.
• Establish separate personal and professional profiles on social networking sites.
• Use different e-mail addresses for private and professional communications to avoid confusion about individual and institutional representation.
• Report unprofessional behavior to regulatory authorities.
• Learn an employer’s social media or social networking policy, if applicable.
• Avoid text messaging or e-mailing patients for medical purposes.
• Actively manage one’s online presence by establishing profiles on social media and professional networking sites. This recommendation can be considered a reminder to social media skeptics that ignoring this technology is not the best response to concerns about professionalism.

Council of Emergency Medicine Residency Directors (CORD)

Noting that emergency medicine physicians appear to be among the most avid physician users of social media, the CORD board of directors published guidelines for social media in 2014, taking into account existing guidelines at medical and nonmedical institutions. They also encourage every residency program and institution to develop its own social media policy and to educate employees about proper use of social media. Echoing the sentiments of other organizations, physicians should uphold the same standards of professionalism and confidentiality online as they would in person. The CORD guidelines highlight several points specifically aimed at residents, such as how senior residents or faculty need to be consistent in their approach to accepting or rejecting friend requests from co-residents to avoid the impression of bias or favoritism.²⁵

How to use social media

In 2015, the issue is not whether physicians should use social media, but how they should use it. The ubiquity of social media makes ignoring the technology nearly impossible and certainly ill-advised. The Internet and social media offer tremendous opportunities for physicians but invariably create serious challenges and potential conflicts. Applying common sense and adhering to “professional offline standards” while online are among the most helpful recommendations for physicians who engage in social media. Fortunately, an increasing number of national physician organizations and health care institutions are issuing guidelines on the proper use of social media. These recommendations can provide valuable guidance and may also serve as the basis of legal action; all physicians should be aware of how the rules apply to them in their respective professional environments. In 2015, what happens online can no longer be ignored offline.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government.

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