Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards

Jeanne M. Farnan; Lois Snyder Sulmasy; Brooke K. Worster; Humayun J. Chaudhry; Janelle A. Rhyne; Vineet M. Arora

doi:10.7326/0003-4819-158-8-201304160-00100

Position Papers |16 April 2013

Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards Free

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*

Article, Author, and Disclosure Information

This article was published at www.annals.org on 11 April 2013.

* This paper, written by Jeanne M. Farnan, MD, MHPE; Lois Snyder Sulmasy, JD; Brooke K. Worster, MD; Humayun J. Chaudhry, DO, MS, SM; Janelle A. Rhyne, MD, MA; and Vineet M. Arora, MD, MAPP, was developed by the American College of Physicians Ethics, Professionalism and Human Rights Committee; the American College of Physicians Council of Associates; and the Federation of State Medical Boards Special Committee on Ethics and Professionalism. Members of the 2012–2013 ACP Ethics, Professionalism and Human Rights Committee: David A. Fleming, MD, MA (Chair); Ana María López, MD, MPH (Vice-Chair); Jeffrey T. Berger, MD; Thomas A. Bledsoe, MD; Clarence H. Braddock III, MD, MPH; David L. Bronson, MD; Nitin S. Damle, MD, MS; Kathy Faber-Langendoen, MD; Phyllis A. Guze, MD; Nathaniel E. Lepp, MPH; Alejandro Moreno, MD, MPH, JD; Upasna (Mini) Swift, MBBS; Jon C. Tilburt, MD; and Michael N. Young, MD. Members of the 2012–2013 ACP Council of Associates: Jay D. Bhatt, DO, MPH, MPA (Chair); Ryan Clark Van Woerkom, MD; John Peter Biebelhausen, MD, MBA; Stephen F. Darrow, MD; Morganna L. Freeman-Keller, DO; Gaurav Jain, MBBS; Ali M. Khan, MD, MPP; Brent Wallace Lacey, MD; Arta Lahiji, MD, MPH; Julissa Lombardo, MD; Thomas E. Reznik, MD; Shruti Tandon, MD; Zoe Tseng, MD; and Michael N. Young, MD. Members of the 2011–2012 FSMB Special Committee on Ethics and Professionalism: Janelle A. Rhyne, MD, MA (Chair); Radheshyam M. Agrawal, MD; Constance G. Diamond, DA; Robert P. Fedor, DO; John P. Kopetski (deceased); M. Myron Leinwetter, DO; Lance A. Talmage, MD; and Bruce D. White, DO, JD. Approved by the FSMB Board of Directors on 21 October 2012 and the ACP Board of Regents on 17 November 2012.

From the University of Chicago, Chicago, Illinois; American College of Physicians and Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania; Federation of State Medical Boards, Euless, Texas; and South East Area Health Education Center, Wilmington, North Carolina.
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, lsnyder@acponline.org.
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.

Abstract

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.

Because of the creation and use of information online and the widespread use of the Internet and Web 2.0 platforms, physicians and others are increasingly required to consider how best to protect patient interests and apply principles of professionalism to new settings (1). As new technologies and practices, such as social networking, are embraced, it is paramount to maintain the privacy and confidentiality of patient information, demonstrate respect for patients, ensure trust in physicians and in the medical profession, and establish appropriate boundaries (2). To protect patients and the public and promote quality health care, it is critical to strike the proper balance to harness opportunities while being aware of inherent challenges in using technology. But as others have pointed out, “Connectivity need not come at the expense of professionalism” (3).

Organizational statements addressing these issues are starting to appear, but they may not provide specific guidance to deal with and anticipate concerns. Innovations often bring benefits, but rapid introduction of technology sometimes outpaces existing policies, laws, and guidelines. This article provides a framework for analyzing medical ethics and professionalism issues in online postings and interactions, including the use of electronic resources for clinical or direct patient care involving patient information outside of the electronic health record, and the nonclinical or personal use of these media. It presents the implications of online activities for patients, physicians, the profession, and society and contains recommendations (Table) that address online communication with patients, the use of social media sites to gather and share information about patients, physician-produced blogs, physician posting of personal information that patients can access, and communications among colleagues about patient care.

Table. Online Physician Activities: Benefits, Pitfalls, and Recommended Safeguards

Here, “online” or “digital” refers to the electronic posting of information and its exchange using computers and phones. “Web 2.0” refers to those resources in which self-created content by users is made and posted for public dissemination by means of media sharing platforms. This article provides guidance for practitioners, trainees, and medical students in navigating the digital world, including the use of social networking, blogging, online forums, media sharing sites, cell phone photography, electronic searching, texting, and e-mailing. It does not examine issues of telemedicine (the care of a patient in an area remote from the consulting physician using the transmission of imaging and health data from 1 site to another), the use of electronic resources to prescribe medicine or diagnose illnesses, social networking resources for patients' therapeutic benefit, or general issues about the electronic health record.

Methods

This position statement was authored on behalf of the American College of Physicians (ACP) Ethics, Professionalism, and Human Rights Committee, the ACP Council of Associates, and the Federation of State Medical Boards (FSMB) Special Committee on Ethics and Professionalism. They and the authors developed the statement between May 2011 and October 2012. After literature reviews and an environmental assessment to determine the scope of issues, drafts were debated, and a consensus was reached on issues through facilitated discussion. A draft then underwent external peer review and review by the College and FSMB committees, councils, and leadership, as well as journal peer review. After revisions based on those comments, the position paper was reviewed and approved by the committees and the FSMB Board of Directors and ACP Board of Regents. The position paper is official ACP and FSMB policy.

Positions

Position 1: Use of online media can bring significant educational benefits to patients and physicians, but may also pose ethical challenges. Maintaining trust in the profession and in patient–physician relationships requires that physicians consistently apply ethical principles for preserving the relationship, confidentiality, privacy, and respect for persons to online settings and communications.

The Patient–Physician Relationship

Standards for professional interactions should be consistent across all forms of communication between the patient and physician, whether in person or online. Encounters between patients and physicians should only occur within the bounds of an established patient–physician relationship, which entails rights and obligations for both parties. As stated in the ACP Ethics Manual, physicians “must be careful to extend standards for maintaining professional relationships and confidentiality from the clinic to the online setting” (4). E-mail and other electronic means of communication can supplement, but not replace, face-to-face encounters.

Establishing positive patient–physician relationships and maintaining professional decorum are core elements of training that should be fostered from medical school through all stages of professional development. Online professionalism can pose challenges because of the ambiguity of written language without the context of body language or lack of awareness of the potential abuses of such media (5). The ease of use and immediacy of social media tools—especially if users do not engage in “pausing before posting”—can lead to unintended outcomes or messages. Many state medical boards have received reports of violations of online professionalism (6).

The initial decision about whether to extend the patient–physician relationship to the online setting includes the following factors: the intended purpose of the exchange and the content of conversation; the immediacy of electronic media and expectations, including response time; how communication will take place (for example, through social networking sites, microblogging, or professional e-mail on a protected server) while maintaining confidentiality; and how emergency or urgent situations will be managed.

The Patient–Physician Relationship: To Friend (and Google) or Not to Friend (and Google)?

Patients will sometimes initiate online communication. One recent study suggested that many patients extend online “friend” requests to their physicians, although very few physicians reciprocate or respond (7). Organizational policy statements increasingly discourage personal communication between physicians and patients online (8). The FSMB specifically discourages physicians from “interacting with current or past patients on personal social networking sites such as Facebook” (9).

Information exchanged on the Web is at least a 2-way street because it may also be available to the general public. Just as patients may learn about the personal behavior of physicians, physicians may observe patients participating in risk-taking or health-averse behaviors. Information about a patient from online sources may be helpful in the care of that patient, but physicians should be sensitive to the source. They should use clinical judgment in determining whether and how to reveal it during their management of the patient.

This online practice, known as patient-targeted Googling, has been described in many settings, including an attempt to identify an unconscious patient in the emergency department. But often, it instead can be linked to “curiosity, voyeurism and habit” (10). Although anecdotal reports highlight some benefit (for example, intervening when a patient is blogging about suicide), real potential exists for blurring professional and personal boundaries. Digitally tracking the personal behaviors of patients, such as determining whether they have indeed quit smoking or are maintaining a healthy diet, may threaten the trust needed for a strong patient–physician relationship (11). Commentators encourage physicians to consider the intent of the search, whether it affects continuing therapy for the patient, and how to appropriately document findings with implications for ongoing care.

Patient and Physician Education

The Internet can be a powerful tool for education. Patients can share and discuss information using illness-specific social networking pages (10). The Pew Internet and American Life Project estimates that 8 in 10 Internet users go online for health information, making it the third most popular activity online among those in Pew Internet surveys (12).

Physicians should consider the quality of online resources they recommend and guide patients to peer-reviewed media and Web sites where the quality control of information can be checked. Using and sharing recommendations from state medical boards or the College may help direct physicians and patients to resources that are more accurate and objective.

Online learning opportunities can be used by patients and physicians. New care delivery models embrace social media, especially for sharing resources in resource-poor environments (13, 14). Online decision aids are growing in popularity among motivated patients seeking health information, and they warrant familiarity by physicians (15). Continuing medical education and faculty development activities are now on the Web, with online learning modules and social media platforms available for specialists and generalists to share experiences and network.

The Internet and social networking can also serve the public health (16). For example, text messaging on a public health level can bring health benefits. But online activities also bring ethical challenges for the profession and individual physicians. Digital media may help to increase physician–physician interaction and education via online discussion communities and similar means; however, it is the responsibility of physicians to ensure to the best of their ability that professional networks are secure and that only verified and registered users have access to shared information. Online postings can also be used to help advocate for public health issues and broadly educate groups of patients on specific conditions and treatment. Clinical vignettes, however, must have all personal identifying information removed, including any revealing references to a patient who serves as the basis for an illustrative narrative. Consent from the patient to use his or her personal story online should be obtained.

Just as with informal in-person discussions among colleagues, the airing of frustrations and “venting” may occur in online forums. The ACP and the FSMB recommend against this practice, even among close contacts, as it may be disrespectful and undermine professionalism. We also caution against this practice in other forums, specifically blog postings or microblog sites, such as Twitter, as the material may present the physician or physician-in-training in an inappropriate or unprofessional light (17). Physicians criticizing late-arriving patients or disparaging patients for not adhering to behavior changes (such as diet and weight loss) can undermine trust in the profession.

Confidentiality

Confidentiality respects patient rights and privacy, and this encourages patients to seek medical care and openly discuss issues. Confidentiality may be hard to maintain given electronic health records, electronic data processing, e-mail, the faxing of patient information, third-party payment for medical services, and the sharing of patient care and information among several health professionals and institutions; therefore, “Physicians must follow appropriate security protocols for storage and transfer of patient information to maintain confidentiality, adhering to best practices for electronic communication and use of decision making tools” (4). In addition, they should be aware of state and federal legal requirements, including the privacy rule from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and updates to the rule (18).

In digital environments, the sharing of patient information must always be held to a higher level of security than standard residential Internet connections. Encrypted or virtual proxy network connections in hospital-based information technology systems should be used for all patient information exchange and review to ensure a secure digital environment. Institutional-based policies on home access of the electronic health record should be reviewed before use, specifically maintaining the level of security required for use on personal devices. Many institutions use mobile device management systems for smartphones and tablet devices. This allows for remote monitoring of the hospital's digital “perimeter” and remote disabling of devices that are lost or confiscated.

Because many physicians use mobile devices to help manage their professional careers, mobile solutions are required to ensure confidentiality, especially when such devices or tablet computers are used to access electronic medical records. Digital devices must be configured to protect patient information should the devices be misplaced or stolen; mobile management solutions can help provide such a safety net (19). In addition, the use of public, unsecured wireless networks and cellular device networks is discouraged given their inherent public accessibility and the potential for patient information to be compromised. The recent Imprivata study of text messaging in health care settings echoes these concerns, with 64% of physician respondents classified as very concerned over HIPAA compliance when sending patient health information by text. Nearly 72% believed that secure text messaging solutions would replace standard numerical pagers in current use within 3 years (20). The disposal of old devices with hospital-based connectivity or access to the electronic health record should be managed on the basis of institutional policy.

With respect to more specific use and sharing of digital media, cell phone photography, for example, is still considered a form of photography. Despite its ease of use and ubiquity, it requires obtaining formal written consent from the patient. In taking a patient photograph or radiographic image, the physician is accepting responsibility to protect this information just as for all health records. Deidentification of radiographic images in the context of educational lectures must be ensured (21).

Medicine and Society

Professionalism is the foundation for the social contract between physicians and society (22). In exchange for the privilege of caring for patients, as well as the status, respect, and financial compensation that accompanies that privilege, society expects physicians to practice in a professional and empathetic manner (23) and to self-regulate (4).

The intimate nature of the relationship between physicians and patients results in the expectation of high ethical behavior by physicians (24). Societal expectations often extend beyond professional practice and into the daily activities of the physician. Poor judgment reflects not only on the individual physician but also on the profession. State medical boards have the authority to discipline physicians, including license restriction, suspension, or revocation, for inappropriate uses of social media, such as improper communication with patients (for example, sexual misconduct), unprofessional behavior, and misrepresentation of credentials.

The ACP Ethics Manual requires that “physicians' conduct as professionals and as individuals should merit the respect of the community” (4). Explicit definitions and expectations of physician behaviors, both in and outside the presence of patients, have been defined by organizations, such as the United Kingdom's General Medicine Council (25).

Position 2: The boundaries between professional and social spheres can blur online. Physicians should keep the 2 spheres separate and comport themselves professionally in both.

Role and Representation

The ACP Ethics Manual stresses the importance of maintaining public trust in the medical profession and in patient–physician relationships. To maintain the respect of the community as individuals and as members of a profession, not only should the content of all online postings be considered but also the role of the individual posting the information. Are individuals posting material in their role as physicians, or are they merely stating opinions and also happen to practice medicine? Can this distinction be maintained?

The American Medical Association strongly suggests divorcing public and professional digital identities, specifically maintaining separate online sites or identities for the separate roles (16). This underscores the importance of education on the use of digital media and pertinent issues of confidentiality. The ACP Ethics Manual states, “Physicians who use online media, such as social networks, blogs, and video sites, should be aware of the potential to blur social and professional boundaries” (4). Problems occur when individuals post questionable material while identifying themselves as a physician or physician-in-training (26–28).

At times, physicians may be asked or may choose to write online about their professional experiences, or they may post comments on a Web site as a physician. When doing so, they must disclose their credentials and any conflicts of interest. They should consider the dangers of posting or responding to comments on the Web. Truly anonymous postings do not exist on the Web, and with the increased sophistication of searching and search engines, the ability to link posts or comments to the original contributor has expanded (29). Physicians should be aware that information posted on a social networking site may be disseminated (whether intended or not) to a larger audience, be taken out of context, and remain publicly available or retrievable online in perpetuity. Physicians should follow their institutional policy on digital media (30) and seek guidance from professional societies and state medical boards.

Maintaining Boundaries

The ACP and the FSMB advise against including patients in the physician's personal and social interactions online. Professional distance and privacy are appropriate for both physician and patient. Physicians should not “friend” or contact patients through personal social media. Physicians should familiarize themselves with the privacy settings and terms of agreements for social media platforms to which they subscribe, and they should maintain strict privacy settings on personal accounts. Professional profiles should be constructed with an explicit purpose (such as networking and community outreach).

Public Consumption

Physicians-in-training, who at present are most apt to use social media platforms, agree on the responsibility to represent themselves professionally online and are aware that they, and the profession, are being assessed by their online behaviors (7). Although narrative work has described the psychological benefit of “collective venting toward the process of being doctored” (31), the public availability of online medical class skits, songs, shows, and other material previously intended for sharing in private, physician-only audiences has called into question these traditions.

Although we will not attempt to dissect the implications of such offerings, it is clear that these are experiences that are not generally intended for public consumption and, despite any value to the psyche of the trainees, should be examined more closely by medical educators and not shared online or in other mass media. It is prudent to consider the effect of publicly posting something that initially seems like harmless medical humor. Consideration should be given to how patients and the public would perceive the material and what effect this may have on the individuals involved as well as their institutions and the medical profession. Many institutional policy statements encourage a “pause-before-posting” moment where medical professionals are asked to reflect on how the general public may perceive the content.

Interprofessional Relationships

Another issue requiring consideration is online relationships between physicians of varying levels of training, specifically, attending physicians and their students and residents. Attending physicians frequently receive online “friend” requests from students and residents (32). These digital “relationships” can also blur professional and personal boundaries, especially when the faculty physician is in the role of evaluator. Faculty and trainees should examine the purpose of initiating an online relationship and decide whether it is for ongoing mentorship, research work, or career advice (32). Regardless of intent, the traditional boundaries encouraged in trainee–faculty relationships should apply when those parties interact through social media. These boundaries should also apply with staff, other clinicians, and allied health professionals.

Position 3: E-mail or other electronic communications should only be used by physicians in an established patient–physician relationship and with patient consent. Documentation about patient care communications should be included in the patient's medical record.

Effective communication is a foundation of a strong patient–physician relationship. E-mail or other electronic communications can supplement face-to-face encounters if done under guidelines (4, 33). Using e-mail to provide therapeutic advice is not recommended when a patient–physician relationship has not been previously established. Some state laws (for example, those in Hawaii) do not require a preexisting relationship for e-mail or other electronic consultation between a physician and a patient (that is, the physician has not met or examined the patient) (34); however, the ACP and the FSMB do not support this practice.

Documentation of communications in an established patient–physician relationship, including those done electronically, should be maintained. “Medical records should contain accurate and complete information about all communications, including those done in-person and by telephone, letter or electronic means” (4).

Situations in which a physician is approached by electronic means for clinical advice in the absence of a patient–physician relationship should be handled with careful judgment; they should usually be addressed with encouragement that the individual schedule an office visit or, in the case of an urgent matter, go to the nearest emergency department.

E-Communication and Established Relationships

E-communication between patients and physicians with an existing relationship requires discussion and previous agreement before electronic exchange is initiated. Guidelines exist for interactions with patients via e-mail (33), including the appropriate type of information to share and the expectations about turnaround time. The nature of e-mail communication ensures a written copy of the exchange, but patient confidentiality must be assured, such as through the use of a hospital-based server. A discussion of the protections in place to ensure patient privacy must also occur.

Documentation of the patient's consent and awareness of the security and risks associated with the use of patient–physician e-mail should be included in the medical record (35). Physicians should not use personal e-mail accounts for these communications but rather encrypted messages over secure network connections. Web-based portals offer messaging through secure accounts on the portal. Physicians must maintain appropriate boundaries (36) and recognize that electronic communication merely supplements face-to-face encounters.

Electronic communication with patients, if done in a systematic and thoughtful way, can improve patient care and outcomes. Studies have demonstrated that in patients with chronic disease management needs, supplemental electronic communication served as a “booster” to physician advice and improved adherence to therapy (37, 38). It may also improve patient and physician satisfaction by increasing the actual or perceived time spent communicating and having questions answered (39). As other Web tools begin to show promise, this communication is often not limited to standard e-mail (40). Physicians and patients should be discouraged from communicating on health matters through social media tools that are publicly viewable, do not ensure patient confidentiality, and are not readily recordable or admissible to the medical record.

Physicians should be aware of legal requirements in their states about these communications and the risk for state medical board violations or other issues if the physician is not licensed in the state in which the electronic communications are received.

“The MD Will BRB [Be Right Back]”

Expectations for immediate access have led to non–Web-based forms of communication by means of multimedia messaging services and short or text messaging services (41). Several large pharmacies and insurers have piloted systems for prescription refills and appointment updates (42); however, these interactions are largely unidirectional (such as update or reminder texts) with several layers of encryption for security. Despite these advances, current technology does not provide adequate security to prevent third-party access to information. Also, text messaging is not analogous to e-mail because of its abbreviated format and the greater possibility of missed messages. Therefore, physicians should not use text messaging for medical interactions with even established patients except with extreme caution and with patient consent.

Position 4: Physicians should consider periodically “self-auditing” to assess the accuracy of information available about them on physician-ranking Web sites and other sources online.

Ranking, feedback, and other Web sites may offer patients insight into physician training and office practices. Physicians and patients should recognize that this information may not be complete or accurate. Physicians may have little recourse in deleting misrepresentations (43–45). Establishing a professional profile so that it “appears” first during a search, instead of a physician-ranking site, can provide some measure of control that the information read by patients before and after the initial encounter is accurate. Physicians should consider doing routine surveillance (46) of their online presence by searching for their names, and they should correct inaccurate information.

Position 5: The reach of the Internet and online communications is far and often permanent. Physicians, trainees, and medical students should be aware that online postings may have future implications for their professional lives.

How one is represented affects public, patient, and peer perceptions. Colleagues may often be superiors or those in an evaluative capacity. The online behaviors an individual displays may harm employability and recruitment, may result in limitations in professional development and advancement, and may reflect poorly on the profession as a whole.

Many institutions have begun to harness the power of digital media to attract patients, new faculty, or trainees, especially in allied health professional education (47). These technologies can be used as recruitment or screening tools. Employers have turned away job applicants on the basis of questionable digital behavior, including provocative or inappropriate photographs or information, content that displays drinking or drug use, and evidence of poor communication skills (48). Anecdotal reports indicate that medical school admissions offices and residency training programs are increasingly using the Web to prescreen candidates. Many trainees may inadvertently harm their future careers by not responsibly posting material or not actively policing their online content. Educational programs stressing a proactive approach to digital image (online reputation) are good forums to introduce these potential repercussions.

The implications for professional life extend beyond being a prospective applicant to career advancement. A physician's digital image can have positive or negative career repercussions. Several very public missteps have been documented, including physicians taking digital photographs during surgery (49), posing with weapons and alcohol (in some instances during humanitarian work) (50), and unprofessional microblog posts (for example, “tweets”) (51) that may ultimately harm both the individual and the profession. One's digital image should be actively managed beyond training by maintaining the separation of professional and personal images and the clinical and nonclinical use of social media. Being proactive by controlling posted content, using privacy settings, and limiting access to personal information is in the best interest of both the profession and the individual physician.

Conclusion

Online technologies present both opportunities and challenges to professionalism. They offer innovative ways for physicians to interact with patients and positively affect the health of communities, but the tenets of professionalism and of the patient–physician relationship should govern these interactions. Institutions should have policies in place on the uses of digital media. Education about the ethical and professional use of these tools is critical to maintaining a respectful and safe environment for patients, the public, and physicians. As patients continue to turn to the Web for health care advice, physicians should maintain a professional presence and direct patients to reputable sources of information.

Digital media use for nonclinical purposes may affect societal perceptions of the profession, especially when questionable content is posted by physicians in their personal use of the Web. Maintaining separate personal and professional identities in Web postings may help to avoid blurring boundaries in interactions with patients and colleagues.

The ACP and the FSMB recognize that emerging technology and societal trends will continue to change the landscape of social media and social networking and how Web sites are used by patients and physicians will evolve over time. These guidelines are meant to be a starting point, and they will need to be modified and adapted as technology advances and best practices emerge. Physicians are encouraged to take a proactive approach to managing digital identity by routinely performing surveillance of publicly available material and maintaining strict privacy settings about their information. Physicians also need to familiarize themselves with these technologies to guide themselves, and their patients, as they navigate the online terrain.

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4 Comments

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

Johns Hopkins

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.

References

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

Authors' Response

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

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Citations

American College of Physicians Ethics Manual: Sixth Edition

Annals of Internal Medicine; 156 (1_Part_2): 73-104

Ethics Manual: Fifth Edition

Annals of Internal Medicine; 142 (7): 560-582

Ethics Manual: Fourth Edition

Annals of Internal Medicine; 128 (7): 576-594

Reflections on Medical Journals: Has Progress Made Them Better?

Annals of Internal Medicine; 137 (1): 46-48

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Position Papers |16 April 2013

Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards Free

Abstract

Table. Online Physician Activities: Benefits, Pitfalls, and Recommended Safeguards

Methods

Positions

The Patient–Physician Relationship

The Patient–Physician Relationship: To Friend (and Google) or Not to Friend (and Google)?

Patient and Physician Education

Confidentiality

Medicine and Society

Role and Representation

Maintaining Boundaries

Public Consumption

Interprofessional Relationships

E-Communication and Established Relationships

“The MD Will BRB [Be Right Back]”

Conclusion

References

Table. Online Physician Activities: Benefits, Pitfalls, and Recommended Safeguards

Clinical Slide Sets

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4 Comments

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Position Papers |16 April 2013

Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards Free

Abstract

Table. Online Physician Activities: Benefits, Pitfalls, and Recommended Safeguards

Methods

Positions

The Patient–Physician Relationship

The Patient–Physician Relationship: To Friend (and Google) or Not to Friend (and Google)?

Patient and Physician Education

Confidentiality

Medicine and Society

Role and Representation

Maintaining Boundaries

Public Consumption

Interprofessional Relationships

E-Communication and Established Relationships

“The MD Will BRB [Be Right Back]”

Conclusion

References

Table. Online Physician Activities: Benefits, Pitfalls, and Recommended Safeguards

Clinical Slide Sets

This feature is available only to Registered Users

4 Comments

See Also

Related Articles

Journal Club

Related Topics

PubMed Articles

Content

Information For

Services

Awards and Cover

Other Resources

Follow Annals On

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