Jeanne M. Farnan, MD, MHPE; Lois Snyder Sulmasy, JD; Brooke K. Worster, MD; Humayun J. Chaudhry, DO, MS, SM; Janelle A. Rhyne, MD, MA; Vineet M. Arora, MD, MAPP; for the American College of Physicians Ethics, Professionalism and Human Rights Committee; the American College of Physicians Council of Associates; the Federation of State Medical Boards Special Committee on Ethics and Professionalism*
Acknowledgment: The American College of Physicians and the Federation of State Medical Boards thank reviewers of this position paper: Mitchell A. Adler, MD; Moises Auron, MD; Deborah L. Baruch-Bienen, MD, MA; Bradley H. Crotty, MD; Robert A. Gluckman, MD; Jay A. Jacobson, MD; Terry Kind, MD, MPH; Arash Mostaghimi, MD, MPA; Susan L. Rattner, MD; Thomas E. Reznik, MD; Michael C. Sha, MD; Earl Stewart Jr.; Thomas G. Tape, MD; Susan Thompson Hingle, MD; Alan H. Wynn, MD; and Annals of Internal Medicine reviewers.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2111.
Requests for Single Reprints: Lois Snyder Sulmasy, JD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572; e-mail, email@example.com.
Current Author Addresses: Drs. Farnan and Arora: University of Chicago, 5841 South Maryland Avenue, M/C2007 AMB W216, Chicago, IL 60637.
Ms. Snyder Sulmasy: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572.
Dr. Worster: Thomas Jefferson University Hospitals, 111 South 11th Street, Philadelphia, PA 19107.
Dr. Chaudhry: Federation of State Medical Boards, 400 Fuller Wiser Road, Suite 300, Euless, TX 76039.
Dr. Rhyne: South East Area Health Education Center, 1601 Doctors Circle, Wilmington, NC, 28401.
Author Contributions: Conception and design: J.M. Farnan, L.S. Sulmasy, H.J. Chaudhry, V.M. Arora.
Analysis and interpretation of the data: J.M. Farnan, L.S. Sulmasy, B. Worster, H.J. Chaudhry, J. Rhyne, V.M. Arora.
Drafting of the article: J.M. Farnan, L.S. Sulmasy, B. Worster, H.J. Chaudhry, V.M. Arora.
Critical revision of the article for important intellectual content: J.M. Farnan, L.S. Sulmasy, B. Worster, H.J. Chaudhry, J. Rhyne, V.M. Arora.
Final approval of the article: J.M. Farnan, L.S. Sulmasy, H.J. Chaudhry, J. Rhyne, V.M. Arora.
Administrative, technical, or logistic support: J.M. Farnan, L.S. Sulmasy, H.J. Chaudhry.
Collection and assembly of data: J.M. Farnan, L.S. Sulmasy, H.J. Chaudhry, V.M. Arora.
User-created content and communications on Web-based applications, such as networking sites, media sharing sites, or blog platforms, have dramatically increased in popularity over the past several years, but there has been little policy or guidance on the best practices to inform standards for the professional conduct of physicians in the digital environment. Areas of specific concern include the use of such media for nonclinical purposes, implications for confidentiality, the use of social media in patient education, and how all of this affects the public's trust in physicians as patient–physician interactions extend into the digital environment. Opportunities afforded by online applications represent a new frontier in medicine as physicians and patients become more connected. This position paper from the American College of Physicians and the Federation of State Medical Boards 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 that preserve confidentiality while best using these technologies.
Table. Online Physician Activities: Benefits, Pitfalls, and Recommended Safeguards
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Karen Devon, MD, Sabha Ganai, MD, PhD
University of Toronto, University of Chicago
April 24, 2013
Online Medical Professionalism Policy Statement
We commend the authors for their thorough and long overdue position statement regarding online professionalism (1). As physicians continue to face new challenges related to online technologies and environments, we would like to highlight some practical challenges.
Despite other societal guidelines advocating the separation of personal and professional online personas (2), we believe that this is neither feasible nor always desirable. While preferable for physicians and patients to maintain certain boundaries in online and offline venues, the distinction between professional and personal roles is unclear. Many prominent and successful physicians share both narratives in public online forums, ranging from prior training experiences to the sports teams they support. These individuals’ thoughtful posts do not cause harm and may enhance views of the profession and the doctor-patient relationship through a combination of transparency, authenticity, and personal connection. Conversely, unprofessional “private” posts can easily be made public through friends, acquaintances, and “friends of friends”. Rather than aiming to have distinct personas, physicians should focus on extending ethical and professional standards to all online behavior (3). Professional accountability, discretion, and judgment must associate with both the personal and the professional.
While state medical boards have authority to discipline physicians for unprofessional conduct (1,4), guidance is still needed on how to regulate online professionalism and respond to unprofessional behavior, especially with the multinational scope of online communication. Furthermore, given the brevity of microblogging platforms, declarations of conflict of interest are not possible and will require innovative solutions.
Although the house call has become an item of primarily historical interest, it represents not only the classic doctor-patient relationship, but also the intersection of private and professional in the practice of medicine. In an era of value-centered care, patients are more empowered to drive the methods of their interactions with their healthcare providers, whether in an office, a one-stop pharmacy, or via a mobile app. By engaging with the public in a manner that is personal, direct, timely, and relevant, physicians can act as patient advocates rather than mere filters of content (5).
Respect must be earned in any social construct. Physicians cannot expect to remain the primary source for health care information without engaging with patients where they are most comfortable. Physicians must work to provide accurate, accessible, and confidential information to patients or they risk a misinformed society.
(1) Farnan JM, Sulmasy LS, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM. Online Medical Professionalism: Patient and Public Relationships: Policy Statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 2013; 158: 620-627.
(2) Shore R, Halsey J, Shah K, Crigger BJ, Douglas SP; AMA Council on Ethical and Judicial Affairs (CEJA). Report on the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media. J Clin Ethics 2011; 22: 165-172.
(3) Guseh JS, Brendel RW, Brendel DH. Medical professionalism in the age of online social networking. J Med Ethics 2009; 584-586.
(4) Greysen SR, Johnson D, Kind T, Chretien KC, Gross CP, Young A, Chaudhry HJ. Online professionalism investigations by state medical boards: first, do no harm. Ann Intern Med 2013; 158: 124-130.
(5) McNab C. What social media offers to health professionals and citizens. Bull World Health Organ 2009; 87: 566-567.
Joy L. Lee, MS; Albert W. Wu, MD, MPH
May 16, 2013
Reality Check Please: Push Back on Professional Policy for Social Media
Dear Editors:The ACP recently published a policy statement on social media (1). This thoughtful document highlights the concerns surrounding the use of social media interactions by physicians: maintaining professionalism, patient confidentiality, and public trust. We believe it also illustrates the difficulty of superimposing parameters on rapidly evolving technologies and social interactions. The Statement emphasizes the importance of maintaining professional boundaries, but such limitations are impractical on certain social media platforms, such as Twitter. This disconnect, between regulation and practice, is especially evident in regards to Position 2.
Position 2 states that “Physicians should keep the [professional and social] spheres separate and comport themselves professionally in both.” It adds that “The American Medical Association strongly suggests divorcing public and professional digital identities, specifically maintaining separate online sites or identities for the separate roles.” While these ideals are laudable in principle, the reality is that on Twitter most users, including physician do not divorce identities and accounts for different roles. For example, Dr. Atul Gawande, a prominent twitterer, uses the same handle for tweeting about his music playlist as for discussing the ACP guidelines. Though we might question his taste (Psy’s “Gentleman” wouldn’t make our checklist), professionalism, confidentiality, and public trust are not violated by this blurring of spheres.Relationship boundaries also blur on Twitter. The ACP and the FSMB “both advise against including patients in the physician’s personal and social interactions online.” While it may be sensible for physicians to refrain from “friending” patients on Facebook, interactions are typically less intimate on Twitter and boundary distinctions more impractical.
For a popular Twitter doctor like Dr. Vineet Arora, for example, it may be difficult to verify the identities and her relationships with all 13,436 of her followers.Furthermore, by restricting online interactions to networking, community outreach, or “research, work or career advice” with trainees, as the guidelines suggest, the ACP overlooks Twitter’s advantages. At the 36th annual Society of General Internal Medicine meeting, many physicians, including one of the authors of this letter used the hash tag #sgim13 to broadcast the presentations, broadening the conference audience and stimulating real time feedback among peers. This activity would seem to have been out of the bounds of use suggested by the Statement. In current practice, Twitter is used as a tool for dissemination, editorializing, and soliciting information among like-minded patients, advocates, colleagues, AND friends. The ACP guidelines should be modified to accommodate this reality.
1. Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM, et al. Online medical professionalism: patient and public relationships: policy statement from the american college of physicians and the Federation of state medical boards. Ann Intern Med. 2013 Apr 16;158(8):620-7. PubMed PMID: 23579867.
Jeanne M. Farnan, MD MHPE; Lois Snyder Sulmasy, JD; Humayun Chaudhry, DO, MS, SM
University of Chicago, ACP, Federation of State Medical Boards
May 22, 2013
We thank Drs. Devon, Ganai, Lee and Wu for their letters on next steps for physician participation in the digital space. While maintaining distinct professional and personal personas is challenging, we agree that examining the level of professionalism of online behavior is critical to trust in and societal perception of the profession. The house call is a useful analogy of a physician—in her professional, not personal capacity—entering the patient’s personal space. It also illustrates changing medical practices and the need to continually reaffirm principles of professionalism. We agree that the distinction between professional and personal roles online has been unclear-- hence the call to make it clearer. This does not preclude physicians providing health information and “engaging patients where they are most comfortable;” it just requires keeping this separate from personal communications.
Additional discussion and guidance will be needed to determine how and when action is taken against those who engage in blatantly unprofessional online behavior. Prior study examining such breaches demonstrates that patients and families have most commonly reported violations such as inappropriate communication with patients online (e.g. of a sexual nature) and physician use of the Internet for “inappropriate practice” (e.g., promising a treatment outcome) (1). There is variability in the assessment and attitude of regulators toward different online behaviors (2), underscoring the importance of continued dialogue among physician-users of social media and state medical boards about appropriate thresholds for intervention. We agree with Drs. Lee and Wu that establishing policy and precedence in the face of rapidly evolving technology is a daunting task and reiterate that professional boundaries are best maintained with deliberate practice. Physicians like Dr. Vineet Arora are adept at sharing succinct and relevant health care commentary, but we believe there is a distinct difference in level of intimacy when such commentary is shared with those who “follow” meeting updates versus those physicians who “friend” others on Facebook and share personal information. Prior research has demonstrated concerns about the latter, with more than half of clerkship directors feeling it was inappropriate to “friend” a current student, resident or patient (3). Tweeting about one’s music tastes or favorite sports team may appear to be a benign activity, but the use of Twitter or related applications to “editorialize” could become a slippery slope and thus we encourage pausing – to assess appropriateness – before posting.
1. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards JAMA. 2012 Mar 21; 307(11):1141-2.
2. Greysen SR, Johnson D, Kind T, Chretien KC, Gross CP, Young A, Chaudhry HJ. Online professionalism investigations by state medical boards: first, do no harm. Ann Intern Med. 2013 Jan 15; 158(2):124-30.
3. Chretien KC, Farnan JM, Greysen SR, Kind T. To friend or not to friend? Social networking and faculty perceptions of online professionalism. Acad Med. 2011 Dec;86(12):1545-50.
Silvio A. Namendys-Silva, MD, MSC, FCCP
Instituto nacional de Cancerologia
November 12, 2013
Should healthcare professionals separate their personal and professional social media? Yes
To the Editor: Recently, DeCamp et al. (1) have highlighted several problems with the recommendations from the American College of Physicians and the Federation of State Medical Boards (2). The guidelines urge physicians to separate their personal and professional social media (SoMe), but DeCamp et al. (1) argue that this separation is impossible. The authors described the following problems with the guidelines: there is a lack of user consensus about the guidelines, the separation of online identities is operationally impossible, and is inconsistent with the general concept of professional identity, and maintaining two identities can generate a psychological or physical burden. The term SoMe is usually applied to describe the various types of media content that are publicly available and created by end-users (3). Kaplan et al. (3) have proposed a classification of SoMe that includes collaborative projects (e.g., Wikipedia), blogs or microblogs (e.g., Wordpress, Twitter), content communities (e.g., Flickr, YouTube), social networking sites (e.g., Facebook, LinkedIn), virtual game worlds (e.g., X-Box, Play Station), and virtual social worlds (e.g., Second Life). However, having two or more SoMe accounts does not mean having more than one identity.On Facebook, people often share family time by uploading photos from vacations, and special events, share videos from parties with people who did not attend, invite coworkers to office events, and play games with friends. However, as a physician, would you be comfortable sharing these things with your patients or professional society? I would not want to share personal photos and videos with people in my professional world. Healthcare professionals should exclude the public and their patients from their SoMe profiles. One way to clarify your goals is to formulate a personal SoMe strategy. For example, if you want to maintain contact with your family and friends, Facebook is an appropriate venue; but if you want to collaborate with your professional society and peers, LinkedIn or Twitter are appropriate (4). Interconnecting various types of SoMe is easy, and the user can decide how the different types interconnect. SoMe is a relatively new concept that is continually being transformed (5), and is also now a permanent fixture in society. Proactive participation in SoMe can be a powerful tool but healthcare professionals should choose the platform that is right for them. New guidelines should distinguish among different types of SoMe.References 1. DeCamp M, Koenig TW, Chisolm MS. Social media and physicians' online identity crisis. JAMA. 2013; 310(6):581-2.2. Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM; American College of Physicians Ethics, Professionalism and Human Rights Committee; American College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013; 158(8):620-627.3. Kaplan AM, Haenlein M. Users of the world, unite! The challenges and opportunities of social media. Bus Horiz 2010; 53:59–68.4. Dutta S. What's your personal social media strategy? Harv Bus Rev. 2010; 88(11):127-30, 151.5. Hamm MP, Chisholm A, Shulhan J, et al; Social media use among patients and caregivers: a scoping review. BMJ Open. 2013;3(5) pii: e002819
Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM, et al. Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158:620–627. doi: 10.7326/0003-4819-158-8-201304160-00100
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