Ask the Experts: Physicians and Appropriate Use of Social MediaAsk the Experts: Physicians and Appropriate Use of Social Media

Social media and connecting through social networking have greatly changed the way we live in the 21st century. Social media continues to change many of our daily activities—from the way we conduct business, to the way we socialize, to the way we access our news, information, and entertainment. Social media is now a common fixture in our everyday lives.

These developments can have a big impact on our professional lives as well as our personal communications. Physicians, and those studying and training to become physicians, are subject to obligations of professionalism, a quality not always found in communications made through social media. If professionalism is not maintained, physicians may be subject to serious consequences. Along with the great benefits of social media, therefore, come challenges, particularly for health care professionals.

The Federation of State Medical Boards (FSMB) is the national non-profit organization representing the various state medical and osteopathic licensing boards of the United States and its territories. Among the ways the FSMB supports its member medical boards is through policy analysis and development, and by issuing recommendations on issues pertinent to medical regulation. It was in this role that the Special Committee on Ethics and Professionalism of the FSMB formulated its Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice.

ECHO staff discussed these Guidelines and the issues they address with Humayun J. Chaudhry, D.O., the President and CEO of the FSMB. In this interview, Dr. Chaudhry gave us a first-person perspective on the reasons for and development of the Guidelines and the recommendations they contain. Dr. Chaudhry also placed these timely issues in the wider context of the evolving role played by these forms of communication in the professional—and personal—lives of physicians today.

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  What prompted the FSMB to learn more about the connection between physician professionalism and social media?

At the Federation of State Medical Boards, we’ve been involved with the intersection of technology and physician professionalism for many years. Medical boards have been taking action against physicians for inappropriate Internet prescribing, which is really where our involvement began in the late 1990’s. The Federation subsequently issued a model policy on the appropriate use of the Internet, back in 2002, but it was primarily focused on Internet prescribing, which was starting to become very popular.

We now know that nearly 90% of physicians use a social media website for personal use and 67% use social media for professional purposes. That’s an astounding number, and one that has grown exponentially over the last decade.

We partnered in conducting a survey of state medical boards, and the results that we started getting back were quite shocking for us.

The study surveyed the 68 executive directors of all medical and osteopathic boards in the United States and its territories about physician violations of online professionalism reported to them, and any subsequent actions taken. The response rate was very good – 71% (48 out of 68 state boards responded). What was really shocking was that 92% of the state boards that responded said that they had had at least one of several types of online professionalism violations reported to their board.

The three most common categories that were identified were:

  • inappropriate patient communication online, for example, sexual misconduct, or asking a patient out on a date;
  • use of the Internet for inappropriate practices, for instance, Internet prescribing without an established clinical relationship with that patient;
  • online misrepresentation of credentials.

  What was most surprising in the survey results?

I don’t think anyone was surprised when a prior survey determined that medical school students were using the Internet in ways that might be deemed unprofessional or inappropriate. There was almost a sense of, “Well, the students are new, they grew up on the Internet, they perhaps don’t fully understand the consequences.”

When we were subsequently approached about doing a study looking at practicing physicians, the notion at that time, perhaps naïve, was “Well, certainly, those who have been in practice for many years would know better…” when using online or Internet capabilities to interact with their patients.

When it was found that it was just as bad, if not worse, with practicing physicians, that was a wakeup call.

  How did the FSMB decide to approach the information it gathered in the survey?

We do a good job of disciplining physicians when something goes wrong, but we thought it was very important for us to be proactive and educate state boards and physicians to stay away from pitfalls, to help them, and to further improve patient care and professionalism.

We formed an ad hoc committee on ethics and professionalism to put together some guidelines, which you now see in the form of the Model Policy Guidelines. The Ethics and Professionalism Committee of the Federation has since become a standing committee, not simply an ad hoc committee, because there are so many issues in this area that the committee will be looking at in the years ahead.

We have also published an article in the Annals of Internal Medicine examining 10 different vignettes—possible scenarios that could get doctors in trouble with social media—and how state boards might respond. In April of this year, the Federation is issuing a joint policy statement with the American College of Physicians on how to stay out of trouble as we use this exciting technology.

  What types of online behaviors would be considered unprofessional for physicians?

We were able to identify a number of categories of unprofessional behavior from our survey, and from our research, relating to the inappropriate use of social networking media:

  • inappropriate communication with patients online, especially when there is a sexual aspect to that;
  • use of the Internet for misrepresentation of credentials;
  • use of the Internet for “unprofessional behavior,” broadly defined;
  • online violations of patient confidentiality, which would be not only a violation of a patient’s privacy but could also be a violation of the Health Insurance Portability and Accountability Act (HIPAA);
  • failure to reveal a conflict of interest online, e.g., if you are a physician on a speaker’s bureau for a particular medication, and at the same time are recommending that medication to patients on whatever social networking platform you are using. Somewhere in there you should mention the fact that you are on that speakers bureau;
  • online derogatory remarks regarding a patient;
  • online depiction of intoxication;
  • discriminatory practices or language online.

All are examples of unprofessional behavior online that could get physicians into trouble.

  What are some potential consequences for physicians engaging in unprofessional behaviors?

In the survey, we didn’t just ask, “How often is this happening?” We also asked the state boards, “What are you doing about these things?”

We were quite impressed that 71% of the boards reported that they had held disciplinary proceedings against physicians with results that could range from restricting a license, to suspending a license, even to revoking, permanently revoking, a physician’s license for serious violations or continuing violations on online media.

  How should physicians use personal social media networking sites to interact with patients?

We have come out very strongly, through the committee, on a particular recommendation in that area, which some may find surprising. This is the recommendation in the Model Policy Guidelines that physicians are discouraged from interacting with current or past patients on personal networking sites such as Facebook. We recommend that physicians should only have online interactions with patients when discussing the patient’s medical treatment within the physician-patient relationship.

The committee feels that these kinds of social interactions should never occur on personal social networking or media websites. The recommendation essentially states that, on sites like Facebook you shouldn’t friend a patient because there are dangers, which the policy goes into in more detail.

  Should physicians avoid communicating with their patients through all social networking means?

There are ways to engage patients, including through employer-led websites. Some large hospital systems have social networking platforms which have safeguards, including HIPAA protections for exchange on material between physicians and patients.

We don’t recommend using Facebook or other social networking sites to engage in those types of professional communications. The danger there is, if you use an open social networking site without those safeguards for patient confidentiality or for HIPAA protections, that you are opening the door to problems.

  What cautions would you suggest for physicians utilizing social media platforms?

Physicians should be aware that any information that they post on a social networking site may be disseminated, whether intended or not, to a much larger audience. What they say may be taken out of context or remain publicly available online in perpetuity, to quote the Guidelines.

You may think you are interacting just with your patient. Yet your patient in a given situation may forward that comment to others, may hit “Like” on the comment, and before you know it, it can become viral. Regardless of your original intention, your comment could be shared by many or grow exponentially, and it can stay there on the Internet basically forever.

I don’t think all physicians fully appreciate that there are serious consequences, not only for patient safety, but also for what probably is the most important piece of paper they will receive in their professional career, their license to practice medicine.

  Can you give an example of how a communication on social media could end up damaging a physician’s reputation?

Your recommendation might be, for instance, to use a new medication that has recently come on the market and that you’ve had good success with. A year later, it may be that that medication becomes banned.

Your comment is now still out there, where you have recommended, with your reputation and stature, that this is a good medication for X, Y, or Z.

There are dangers in making any sort of pronouncements, or any clinical recommendations, on a social networking site which potentially could stay there forever.

  What are some positive ways physicians can employ social media?

We do want to encourage physicians to use social media, and technology generally, because we feel very strongly that it can enhance physician-patient communications, especially within the context of a physician-patient relationship.

Social media has enormous potential for both physicians and their patients, to make their relationships more meaningful, to improve access to care, especially in follow-up. If the patient has a question and you have already seen him/her, you may not necessarily need to see them again a week later in order to communicate. Social media might permit an additional way for a patient, perhaps busy or working or finding it difficult to have the opportunity to call, an additional means to get results of a lab, or to ask a follow-up question. The patient can do so online, in a fashion that is streamlined, effective, and has safeguards.

I think this technology brings great advantages to streamline and make more efficient the practice of medicine, which is badly needed. What we’re suggesting is it should be done with an awareness of the context, and an awareness of some of the pitfalls.

  Is there any reason why people, even when professional in other areas, may engage in unprofessional behavior when using social media?

This is perhaps a reflection on human nature—people seem to say things online that they would be less likely to say in person. That seems true, not only in the physician-patient relationship, but also seems to exist routinely among people who communicate online.

There’s something about being online that seems to lower barriers to communication. In one sense, that may be good. In another sense, however, in the physician-patient context, that could cause physicians to say things they otherwise might not say, whether in terms of recommendations or in terms of actions, as they relate to a particular diagnosis that they are managing.

I have been fortunate to have worked in a number of different medical settings, and from those differing perspectives I have seen it to be so true that there is something about the Internet that is hard to define, which enables people to feel free to say things, sometimes at length, that they would never dream of saying in person.

While there’s an advantage to that, from the artistic or creative point of view, there are also dangers to keep in mind.

  Are there some social media platforms that are more effective for physicians than others?

We debated whether the committee should try to canvass what’s out there, in the interest of giving some guidance. But it’s so dynamic out there. That’s why, in the end, the Guidelines are what they are today. But it may have to change to adapt to what may come in the future.

We did decide to give one example of a professional network that is being used to engage in conversations among physicians, which is HIPAA-compliant, and which appears to have some safeguards in place. This is Doximity—we’re not endorsing it. This network already has some 567,000 physician members, in 87 specialties, now using it.

I use it, for instance, though not every day. This is a way for physicians to stay in touch and know that they are dealing with other physicians. Even there, I think physicians have an obligation to make sure that they don’t mention names, certainly, or enough identifying features so that someone could put two and two together, and make it apparent who is being discussed.

  How have you successfully used social media?

For personal use, I use Facebook. I also use Twitter for professional purposes in sharing my thoughts, or in sharing professional news items related to medical regulation that I want my “followers” to be aware of. I don’t have as many followers as Lady Gaga, but there is a close-knit group of people who follow me and are interested in what I say.

I’ve had numerous tweets. Initially, I was very cautious, as all leaders of organizations have to be. We have public relations folks, and communications folks, and marketing folks who can be a bit nervous about someone like myself, in a leadership position, tweeting on my own — I don’t use my staff to tweet, I tweet on my own.

It’s something I have embraced. Not only do I have followers, but I also follow others. People I may respect, people I may admire, I follow. That enables me to get a heads-up on their thinking, or on policy papers, or on guidelines that they may be thinking about.

I thought I was so busy I wouldn’t have time for something like Twitter, but now I make time. It provides me with additional pieces of information that help me do my job more effectively. I am not a practicing physician any longer—I practiced internal medicine for 17 years—but if I were, I would certainly try to utilize the Internet to engage in communications with my patients.

  What are the helpful things physicians may learn through utilizing social media?

The value to the physicians, aside from being able to deliver better health care, lies in what they can learn through, let’s say, Doximity. You can share anecdotes, or maybe even get a heads-up on a side effect of a medication, which may not yet be an official side effect. It’s very possible that, through the Internet, one can identify a problem with a therapeutic approach before it becomes a black box warning. So there are real benefits for quality health care education in making physicians aware of something, in whatever ways that may be done.

  Any concluding thoughts for a physician considering whether, and how, to incorporate social networking into his or her life, professional and personal?

Be careful about what you write. Be careful about some of the dangers already discussed about confidentiality. And be aware that your comment may have a life beyond that which you intended.

By all means, if a physician wants to engage on Facebook—enjoy, for social purposes!

If a physician wants to use social media for professional interactions, use some of the sites that have safeguards in place. As we have pointed out, many employers and health systems have those processes in place. Most doctors have an affiliation with a hospital, where they have admitting privileges. Most hospitals have, or soon will have, platforms with the necessary safeguards so that you can engage in professional interactions.

We have moved far ahead from the days when you only had a single e-mail address, or when people couldn’t reach you when you were on vacation. That time no longer exists—but you still need safeguards.

  For further reference concerning physicians and the use of social media:

The Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice, proposed in the Report of the Special Committee on Ethics and Professionalism of the Federation of State Medical Boards, may be found at https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/pub-social-media-guidelines.pdf.

Physician Violations of Online Professionalism and Disciplinary Actions: A National Survey of State Medical Boards, the study which surveyed 68 executive directors of the medical and osteopathic boards in the United States and its territories about violations of online professionalism reported to them and subsequent actions taken, was published in the March 21, 2012, issue of the Journal of the American Medical Association (JAMA) at http://jama.jamanetwork.com/article.aspx?articleid=1105088.

Online Posting of Unprofessional Content by Medical Students, the study assessing the online posting of unprofessional content by medical students, was published in the September 23, 2009, issue of JAMA at http://jama.jamanetwork.com/article.aspx?articleid=184624.

Online Professionalism Investigations by State Medical Boards: First, Do No Harm, the study gauging consensus among state medical boards in the United States about the likelihood of investigation for specific violations by physicians of online professionalism, was published in the January 15, 2013 issue of the Annals of Internal Medicine at http://annals.org/article.aspx?articleid=1556363.

Online Medical Professionalism: Patient and Public Relationships: Policy Statement from the American College of Physicians and the Federation of State Medical Boards, a position paper that examines and provides recommendations about the influence of social media on the patient-physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician-physician communication, was published in the April 16, 2013, issue of the Annals of Internal Medicine at https://annals.org/article.aspx?articleid=1675927.

About the Expert

Humayun J. Chaudhry, DO, MS, FACP, FACOI

Humayun J. Chaudhry, DO, MS, FACP, FACOI
President and Chief Executive Officer
Federation of State Medical Boards

Dr. Humayun “Hank” Chaudhry is the President and CEO of the Federation of State Medical Boards (FSMB). He was previously Commissioner of Health Services for Suffolk County, New York, overseeing the ninth largest health department in the United States. He is board-certified in internal medicine and is a clinical associate professor of internal medicine at the University of Texas Southwestern Medical School and clinical associate professor of preventive medicine at Stony Brook University School of Medicine in New York. Dr. Chaudhry graduated in 1991 from the New York Institute of Technology College of Osteopathic Medicine and has Master’s degrees from New York University and Harvard School of Public Health. He completed a residency in internal medicine at Winthrop-University Hospital in Mineola, New York, where he was chief medical resident, and served as a flight surgeon in the United States Air Force Reserve, rising to the rank of Major. He is the primary author of Fundamentals of Clinical Medicine, a medical textbook published by Lippincott Williams & Wilkins in 2004, and a co-author with David Johnson of Medical Licensing and Discipline in America, published in 2012 by Lexington Books. He will become a Master of the American College of Physicians in 2013.

Dr. Chaudhry brings rich perspective to the subject of social media and social networking as they relate to medical practice. As Commissioner of Health Services for New York’s Suffolk County, during the 2009 flu pandemic, Dr. Chaudhry used the advantages of these evolving technologies (e.g., BlackBerry, Twitter) in tracking the virus and keeping in close communication with local, state, and federal health officials. His position with the FSMB, his experience in medical licensure regulation, and his professional utilization of social media qualify him uniquely to speak to these subjects.

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