Using social media:

practical and ethical guidance for doctors and medical students

STANDING UP FOR DOCTORS

Introduction
The popularity of social media has grown rapidly in recent years. There is widespread use of sites such as Facebook and Twitter amongst medical students and doctors and there are a growing number of well-established blogs and internet forums that are aimed specifically at medical professionals, such as doctors.net.uk and the BMJs doc2doc. While many medical professionals use social media without encountering any difficulties, media interest and research into examples of unprofessional behaviour online have raised concerns that some doctors and medical students may be unknowingly exposing themselves to risk in the way they are using these web 2.0 applications and uploading personal material onto the internet. Although medical professionals should be free to take advantage of the many personal and professional benefits that social media can offer, it is important that they are aware of the potential risks involved. This guidance provides practical and ethical advice on the different issues that doctors and medical students may encounter when using social media.

Key points: Social media can blur the boundary between an individuals public and professional lives Doctors and medical students should consider adopting conservative privacy settings where these are available but be aware that not all information can be protected on the web The ethical and legal duty to protect patient confidentiality applies equally on the internet as to other media It would be inappropriate to post informal, personal or derogatory comments about patients or colleagues on public internet forums Doctors and medical students who post online have an ethical obligation to declare any conflicts of interest The BMA recommends that doctors and medical students should not accept Facebook friend requests from current or former patients Defamation law can apply to any comments posted on the web made in either a personal or professional capacity Doctors and medical students should be conscious of their online image and how it may impact on their professional standing

Ethical responsibilities and social media

Patient confidentiality
Social media, through blogs and web forums, can provide doctors and medical students with a space in which they can discuss their experiences within clinical practice. As material published on the internet often exists in the public domain however, it is important that health professionals exercise caution when discussing any details relating to specific medical cases. Doctors and medical students have a legal and ethical duty to protect patient confidentiality. Disclosing identifiable information about patients without consent on blogs, medical forums or social networking sites would constitute a breach of General Medical Council (GMC) standards and could give rise to legal complaints from patients. GMC guidance highlights that many improper disclosures are unintentional and reminds medical professionals that they should not share identifiable information about patients where it may be overheard, including in internet forums.1 Although individual pieces of information may not alone breach patient confidentiality, the sum of published information could be sufficient to identify a patient or their relatives. Doctors and medical students who wish to publish details about specific medical cases or clinical experiences online, which identify or run the risk of identifying a patient, should ensure they follow the guidelines relating to patient consent and disclosure set out by the GMC. The BMA also provides extensive guidance for doctors on confidentiality.2 Appropriate discussions of patients and practice While discussion about patients and clinical experiences amongst colleagues online can have both educational and professional benefit, informal discussion about patients on public internet forums should be avoided. It would be particularly inappropriate for medical professionals to make personal or derogatory comments about their patients or colleagues. Even where doctors or medical students post anonymously and are confident that what they say will not breach patient confidentiality, they should consider how such comments will reflect on themselves as physicians or future doctors and bear in mind the potential impact they could have on the publics trust in the medical profession as a whole.

Maintaining boundaries the doctor-patient relationship

Privacy and personal information As the example below illustrates, social media can blur the boundary between an individuals private and professional lives. People are often unaware that the personal material they intend to share with friends could be accessible to a much wider audience and that once uploaded onto the web, it may not be possible to delete material or control how widely it is shared.

Public or Private?
In 2010, a civil servant complained to the Press Complaints Commission (PCC) that two newspapers had breached her privacy by publishing updates she had posted on Twitter in a personal capacity. In the posts, the civil servant revealed that she was struggling with a wine-induced hangover at work and posted a number of tweets that were political in nature. Although initially only intended to be shared with her 700 hundred followers on Twitter, publication in the national press ensured that millions read her tweets. One of the newspapers also published a picture of the civil servant that she had posted on her Flickr page to accompany the article. The newspapers in question argued that the articles were justified given civil service guidelines on impartiality and they had not invaded her privacy because access to the Twitter account had not been limited to just those officially following her. In 2011, the PCC found in favour of the newspapers. It stated that the publically accessible nature of the information was a key consideration in deciding whether it was private and noted that the material published on the site related directly to the civil servants professional life.3

Although doctors often choose to divulge personal information about themselves during face-to-face consultations with patients, they are able to control the extent and type of this self-disclosure. The accessibility of content on social media however raises the possibility that patients may have unrestricted access to their doctors personal information and this can cause problems within the doctor-patient relationship. In an example reported in the MDU Journal, a patient treated by one of the female partners at a GP practice began sending the doctor flowers and other gifts. After the patient attempted to contact the doctor several times on Facebook, it became clear that he had discovered information about the type of presents she might like through the personal information that was easily accessible on her account.4 Some social media sites, such as Twitter and Facebook, have privacy settings that allow users to control and put restrictions on who has access to their personal information.5 The default settings for both sites however permit various types of content to be shared beyond an individuals network of friends. On Twitter for example, the default setting for accounts is public, allowing anyone to search for and access a users

profile page, while the recommended settings on Facebook allow everyone to access status updates, photos and posts. Users therefore actively need to change the privacy controls to ensure their content is protected to the extent they would like. Research from the US suggests however that a proportion of medical professionals may not be taking advantage of these settings to limit access to their profile, despite some accounts displaying content that could be interpreted negatively.6 The BMA recommends that doctors and medical students consider adopting conservative privacy settings where available, but they should also be aware that not all content on the web can be protected in this way. Medical professionals need to be conscious at all times of who has access to their personal material online and how widely this content may be shared. Facebook friend requests Relationships between doctors and patients that are not based around clinical care can raise a number of significant ethical issues. Because of the power imbalance that can exist in any doctor-patient relationship, it is important that a professional boundary exists to maintain trust and protect patients from the possibility of exploitation. It is possible, and in small communities likely, that doctors may have friends who are patients. In these circumstances, doctors and medical students should be aware of the boundaries that need to be set and be sensitive to the need to maintain a professional relationship in the surgery or clinic. Some doctors and medical students report that current or former patients have sent them friend requests on Facebook. While most doctors would not consider entering into an informal relationship with a patient online, research suggests that a small number of doctors have accepted friend requests from patients and that some doctors would decide on an individual basis.7 Given the greater accessibility of personal information, entering into informal relationships with patients on sites like Facebook can increase the likelihood of inappropriate boundary transgressions, particularly where previously there existed only a professional relationship between a doctor and patient. Difficult ethical issues can arise if, for example, doctors become party to information about their patients that is not disclosed as part of a clinical consultation. The BMA recommends that doctors and medical students who receive friend requests from current or former patients should politely refuse and explain to the patient the reasons why it would be inappropriate for them to accept the request.

Declaring conflicts of interest

US research into the content of medical blogs written by healthcare professionals found a number of cases where authors had explicitly promoted or endorsed a specific healthcare product but had not provided information on potential conflicts of interest.8 Doctors and medical students who post material online should be aware of their ethical obligations under GMC regulations to declare any financial or commercial interests in healthcare organisations or pharmaceutical and biomedical companies.9 This ethical duty applies even where doctors blog anonymously, as any material written in a professional capacity or by authors who represent themselves as doctors are likely to be viewed by the public as such and taken on trust. Failing to declare conflicts of interests could undermine public trust, compromise the professionalism of authors and in turn risk referral to the GMC.

Medical education and employment

The erosion of the private-professional boundary can have a negative impact on the relationship between an individual and their employer. Organisations may have access to publically available personal content uploaded by doctors on social media and any material judged to be inappropriate could have a detrimental impact on their professional standing. As indicated in the example below, evidence of unprofessional behaviour can also lead to disciplinary action.

In 2009, a group of doctors and nurses were suspended for taking part in the The Lying Down Game, an internet craze where participants take pictures of themselves lying face down in unusual places and upload them onto Facebook. The group were reported to hospital management after pictures of them lying on resuscitation trolleys, ward floors and the ambulance helipad were spotted on the site. The pictures broke hospital regulations and breached NHS and Trust codes of conduct. The medical director for the trust stated that the group faced disciplinary action because they expected high standards of behaviour from their staff and such breaches were taken very seriously.10

Medical students also need to be conscious about the image they present on social media. Guidance published jointly by the GMC and Medical Schools Council (MSC) reminds medical students that because they have certain privileges and responsibilities different from those of other students...different standards of professional behaviour are expected of them.11 US research into the material posted online by medical students, as reported by deans of medical schools responding to the study, found patient confidentiality violations; instances of discriminatory language and profanity; and depictions of intoxication and illicit substance use, which in some cases resulted in official warnings from medical schools and dismissal.12

There are anecdotal reports that organisations are using the web to screen applicants as part of the recruitment process. Any material on social media that shows candidates in a bad light could potentially jeopardise job or medical school applications and damage career prospects. Doctors and medical students should consider reviewing their content on a regular basis and remove any material they are not comfortable with displaying online.

Defamation
It is important that medical professionals are able to engage fully in debates about issues that affect their professional lives and increasingly the internet is the forum in which this discourse takes place. The freedom that individuals have to voice their opinions on forums and blogs however is not absolute and can be restricted by the need to prevent harm to the rights and reputations of others. Defamation law can apply to any comments posted on the web, irrespective of whether they are made in a personal or professional capacity. Defamation is the act of making an unjustified statement about a person or organisation that is considered to harm their reputation. If an individual makes a statement that is alleged to be defamatory, it could result in legal action against the individual and the organisation they are representing. People can often feel less inhibited when posting comments online and as a result may say things they would not express in other circumstances. Posting comments under a username does not guarantee anonymity as any comments made online can be traced back to the original author. Doctors and medical students need to exercise sound judgement when posting online and avoid making gratuitous, unsubstantiated or unsustainable negative comments about individuals or organisations.

Professionalism and social media

Binding professional duties that doctors and medical students have to their patients are set out in GMC guidance; breaches of these standards while using social media, such as improper disclosures of patient information, represent clear cases of professional misconduct that can call into question the fitness to practise of a doctor or medical student. Medical professionalism however also encompasses a broader, less well-defined set of standards that lie outside the scope of GMC regulations. These principles have evolved with medical practice over time and, while not legally binding, they represent the standards of conduct broadly expected of health professionals by their medical peers and society. Although the way medical professionals use social media in their private lives is a matter for their own personal judgement, doctors and medical students should consider whether the content they upload onto the internet could compromise public confidence in the medical profession.

For further information about these guidelines, BMA members may contact:
The BMA on 0300 123 123 3 or British Medical Association Department of Medical Ethics, BMA House Tavistock Square, London, WC1H 9JP Tel: 020 7383 6286 Fax: 020 7383 6233 Email: ethics@bma.org.uk

References
1 2 3 4 5 General Medical Council (2009) Confidentiality. London: GMC, para 13. See www.bma.org.uk/ethics Press Complaints Commission (2011) Baskerville vs Daily Mail (2010) http://www.pcc.org.uk/news/index.html?article=NjkzNA (accessed 22 Mar 2011). Cuzner E. The hidden dangers of social networking. MDU Journal Vol. 25 Issue 2 (November 2009), p.13. For more information on how to change privacy settings on Twitter and Facebook see: Twitter Help Centre, About Public and Protected Accounts support.twitter.com/entries/14016-about-public-andprotected-accounts (accessed 21 Mar 2011) and Facebook, Help Centre Privacy www.facebook.com/help/?page=419 (accessed 21 Mar 2011). 6 Chretien KC, Azar J, Kind T. (2011) Physicians on Twitter JAMA 305(6):566-568. Thompson LA, Dawson K, Ferdig R, et al. (2008) The Intersection of Online Social Networking with Medical Professionalism. J Gen Intern Med 23(7): 954-7. 7 8 9 10 Moubarak G, Guiot A, Benhamou Y, et al. Facebook activity of residents and fellows and its impact on the doctor-patient relationship. J Med Ethics 2011;37: 101-104. Lagu T, Kaufman EJ, Asch DA, et al. (2008) Content of Weblogs Written by Health Professionals. J Gen Intern Med 23(10):1642-6. General Medical Council (2006) Good Medical Practice. London: GMC, paras 74-76. Anon (2009) Doctors suspended after playing Facebook Lying Down Game. The Telegraph, 9 September. www.telegraph.co.uk/technology/facebook/6161853/Doctors-suspended-after-playingFacebook-Lying-Down-Game.html (accessed 13 Feb 2011). 11 12 General Medical Council and Medical Schools Council. (2009) Medical Students: professional values and fitness to practice. London: GMC, para 3. Chretien KC, Greysen SR, Chretien JP, et al. (2009) Online Posting of Unprofessional Content by Medical Students. JAMA 302(12):1309-1315.