First-place essay—Con: The writing is on the (Facebook) wall: The threat posed by social media

The Moving Finger writes; and, having writ,
Moves on: nor all thy Piety nor Wit
Shall lure it back to cancel half a line,
Nor all thy Tears wash out a Word of it.¹

—Rubáiyát of Omar Khayyám

Social media, the hallmark of Web 2.0, refers to virtual Internet communities where user-generated content (photos, videos, and so on) is shared with others.² Popular sites include Facebook, with 936 million daily users, and Twitter, which boasts more than 500 million daily user updates (“tweets”).^3,4 Social media allows individuals to engage in real-time communication in a manner once unfathomable. However, the power of this technology confers not only benefits, but also potential consequences for misuse.

Social media is possible, in part, because the Telecommunications Act of 1996 protects website operators from legal responsibility for user-generated content.⁵ The user may face civil liability for defamatory or illegal content.⁶ This situation puts users at risk because social media collapses a wide range of audiences from varying communities, backgrounds, and interests into a single context. The audience intended or imagined by the user may be discreet in theory, but it is not necessarily bound by discretion in practice.⁷ Techniques employed in face-to-face conversation—when talking to a patient, for example—are not easily applied to social media because the user is unable to determine identifying characteristics of the audience or the specific context of communication for the audience. In effect, the era of social media has created a platform where patient, colleague, relative—in fact, the entire world—all become part of the same unlimited audience.

Furthermore, communications with this audience are indelible and irrevocable. This new reality must give pause to the prudent surgeon. While social media creates new opportunities, these platforms also threaten patient privacy and challenge the professionalism of surgeons.

A question of privacy

Surgeons are ethically and legally obligated to protect the privacy of their patients. Most physicians in the U.S. swear an oath, typically the Hippocratic Oath, upon graduation from medical school. Nearly all versions of these medical oaths recognize the importance of patient privacy; for example, the wording of one modern version states, “I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.”⁸ In contradistinction, the Twitter Privacy Policy reminds users, “What you say on Twitter may be viewed all around the world instantly.”⁹

Social media has created several tempting platforms for surgeons to share their experiences, but sharing any information about the clinical care of patients may violate patient privacy and the Health Insurance Portability and Accountability Act (HIPAA). While blatant confidentiality breaches seem easy to avoid, they have occurred. Last year, a number of hospital executives in China were fired after a “surgery selfie” photo was shared on social media showing a group of surgeons posing around an unconscious patient during an operation.¹⁰ Fortunately, these overt violations are infrequent, but they do serve as a warning to others that severe disciplinary action and loss of employment may result from inappropriate use of social media.

Less obvious and more insidious violations of patient privacy are more commonplace. A multi-institution study of Facebook use among surgical residents at 57 residency programs revealed that 12.2 percent of users with public profiles had posted unprofessional content, including items that were in violation of HIPAA.¹¹ A study at a single institution found that 14 percent of surgical residents and faculty had content publicly available on Facebook that referenced specific instances of patient care.¹² Surgeons and trainees must remember that, even when patient names or identifiers are excluded from social media sharing, it is still possible to identify patients with minimal information. To meet the legal and ethical requirements of maintaining patient privacy, it is important to avoid specific references to patient care when using social media.

Protecting the profession’s integrity

Professionalism is the foundation of the surgeon’s relationship with patients and society. Surgeons must remember that their presence on social media reflects not only upon themselves as individuals, but also upon the entire surgical profession. The multi-institution study previously mentioned also revealed that surgical residents commonly have unprofessional content on their publicly accessible Facebook pages, including references to binge alcohol use and sexually explicit content.¹¹ Another study found that 3 percent of tweets by self-identified physicians on Twitter were unprofessional, and surgeons comprised the largest subset of physicians in this study when identified by specialty.¹³ Although privacy settings are available for users to limit who may view their activity on social media, users sometimes neglect to turn on these settings or misunderstand how to use them. However, the point of social media is to share, rather than withhold, information. One way to avoid sharing unprofessional content on social media is to avoid sharing personal content altogether.

Accepting personal responsibility

Khayyám’s poem, quoted at the beginning of this article, described the downfall of the Babylonian kingdom, as foretold by a disembodied hand that wrote a message on a wall. Derived from this story is the idiom often used to portend doom: “the writing on the wall.” Social media is not all doom and demise, of course, but it becomes the responsibility of the surgeon to harness this opportunity in a professional and thoughtful manner. The threats to patient privacy and professionalism require constant vigilance from surgeon users. The savvy surgeon would do well to remember, as stated in Twitter’s Privacy Policy, “You are what you tweet.”⁹ Likewise, you are the writing on your Facebook wall. Although the writing may not lead to imminent demise, it is indelible, and the potential consequences are real and enduring.

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References

1. FitzGerald E (ed). Rubáiyát of Omar Khayyám. Boston, MA: Branden Publishing Company; 1992.
2. DiNucci D. Fragmented future. Available at: http://darcyd.com/fragmented_future.pdf. Accessed September 8, 2015.
3. PR Newswire. Facebook investor relations. Facebook reports first quarter 2015 results. Press release. Available at: www.prnewswire.com/news-releases/facebook-reports-first-quarter-2015-results-300070539.html. Accessed September 8, 2015.
4. Twitter, Inc. About Twitter. Available at: about.twitter.com/company. Accessed September 8, 2015.
5. Public Law 104-104th Congress. Telecommunications Act of 1996. Available at: www.gpo.gov/fdsys/pkg/STATUTE-110/pdf/STATUTE-110-Pg56.pdf. Accessed April 23, 2015.
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9. Twitter, Inc. Twitter Privacy Policy. Available at: twitter.com/privacy?lang=en. Accessed April 29, 2015.
10. Ng N. Chinese doctors punished for so-called “surgery selfies.” CNN News. Available at: www.cnn.com/2014/12/23/world/asia/china-doctor-selfies/. Accessed April 29, 2015.
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12. Landman MP, Shelton J, Kauffmann RM, Dattilo JB. Guidelines for maintaining a professional compass in the era of social networking. J Surg Educ. 2010;67(6):381-386.
13. Chretien KC, Azar J, Kind T. Research letter: Physicians on Twitter. JAMA. 2011;305(6):566-568.