Social Media & Professionalism Opinion

North American Neuro-Ophthalmology Society

Advisory Opinion - Social Media and Professionalism


This advisory opinion is an adaption of the American Academy of Ophthalmology Advisory Opinion and edited with their permission.

Subject
Social Media and Professionalism

Issues Raised
What are the ethical issues and risks to professionalism inherent in social media use?

Applicable Rules
Rule 2.1. Professional Competence
Rule 6.1. Public Communication
Rule 4.0. Conflicts of Interest
Rule 2.3. Patient Confidentiality

Background
Social media refers to the interactions among people in which they create, share, and exchange information and ideas in virtual communities and networks.1 In this Advisory Opinion, we use the term to include email, blogs and micro-blogs (such as Twitter), internet forums (such as doctors.net), content communities (such as YouTube and Flickr), and social networking sites (such as Facebook and LinkedIn). As a blend of technology, social interaction, and information sharing, social media is a new paradigm for society and has created an extraordinary transformation of cultural communication.

It has enabled the sharing of health information that is unprecedented in the medical profession’s long history. Due to the relative expansion of this form of communication, only recently have user-guidelines been published by various state boards of medicine and professional medical associations. These guidelines, however, appear to offer conflicting information for the social media user. The guidelines agree on strict adherence to privacy, the need to maximize one’s personal online privacy settings, and recommendations to separate personal and public personas. However, there is a lack of consensus on several points, including medical information posted by the patients themselves, anonymous physician postings, posting patient information with consent even after a patient posts it publicly, and managing conflicts of interest. 2

Although incomplete or imperfect, published guidelines may be helpful for the user because, lacking precedent for this sort of cultural shift, the medical profession has few role models for physicians regarding appropriate social media behavior. Social media has changed traditional physician-patient communication by decreasing the knowledge gap between physician and patient thus equalizing access to many types of health-related information. For patient-users, it has also changed the sanctity of the confidential physician – patient relationship primarily by patients’ purposeful online sharing of confidential information and the inadvertent online disclosure of confidential information by friends and family. There is also a new term to add to our professional parlance, “medical surveillance,” that describes physician-trolling of patient communications on blogs, web sites, and other platforms to gather information about existing patients or for research purposes.

Ethical concerns related to professionalism and the use of social media include the physician’s competence to serve as an online expert, appropriate use of social media in research studies, use of appropriate communication standards, disclosures of relevant conflicts of interests, and adherence to the confidentiality of the physician-patient relationship. All communications with patients, the public, and colleagues, whether via social media or in more traditional frameworks, must adhere to appropriate standards of ethics and professionalism to maintain the public’s trust in the medical profession.

General Discussion
In the face of conflicting guidelines, the following general recommendations for the use of social media, based on the North American Neuro-Ophthalmology Society's Code of Ethics, are made to educate the physician and to protect patients and the profession. Ultimately, it is the responsibility of the physician to act in the best interest of the patient, regardless of what type of communication medium is used.

Rule 2.1. Professional Competence. The physician should be competent by virtue of specific training or experience to act as an online expert and should have a legitimate reason for adding to an ongoing online dialogue. Social media provides a very low bar for declaring yourself an expert, thus a true medical expert should make his or her identify and qualifications known.

Rule 6.1. Public Communication. As in all professional communications to the public, promotions or information provided on social media should be offered in a manner that is not false, deceptive or misleading, including information about the participating physician’s skills, training, or experience. Ideally, physicians should offer evidence-based, scientifically valid information that is 1) useful to the intended audience, 2) understandable to the intended audience, and 3) in an appropriate, shareable format. The physician should identify him or herself and his/her institutional or representative affiliations. If a communication via social media results from payment by or on behalf of a physician, this must be disclosed unless the nature, format or medium makes it apparent.

Rule 4.0. Conflicts of Interest. A conflict of interest exists when professional judgment concerning the well-being of a patient, or the information provided to a patient population via social media, has a reasonable chance of being influenced by other interests of the provider. In a 2008 study, 31% of physician blogs contained product endorsements lacking disclosure3 and in a 2011-2012 survey, 20% of state medical boards noted failed online disclosures on the part of physicians.4 If a physician is compensated in any manner for his/her participation in a social media setting or if a posting contains a relevant product endorsement, the payment and/or the potential conflict of interest should be disclosed as part of the posting. The brevity of social media posts complicates disclosure, thus the physician must make a concerted effort to assure appropriate disclosure. Disclosure of a conflict of interest is required in communications to patients, the public, and colleagues.

Rule 2.3. Patient Confidentiality. Special consideration should be taken when using social media to safeguard confidential health information consistent with the law. As in all public communications, physicians should refrain from using patient identifiers in order to maintain confidentially and to protect patient privacy. Interestingly, social media has engendered a social willingness to share private health information far beyond the boundaries of traditionally-held norms of confidentiality, which may complicate the physician’s efforts to maintain patient confidences.

The HIPAA Privacy Rule5 allows physicians and other health care entities to rely on “professional ethics and best judgments” when determining whether to disclose confidential information in certain permitted circumstances. However, even if a patient has revealed confidential information about themselves on a social media platform, the physician should consider obtaining express permission from the patient before following suit. The federal Office of Civil Rights, which is responsible for HIPAA regulations and enforcement, defines a breach of confidentially under HIPAA as, “… an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information such that the use or disclosure poses a significant risk of financial, reputational, or other harm to the affected individual.”6 There are no restrictions on the use or disclosure of de-identified health information.

When queried directly, physicians may be tempted to offer online medical advice; however, issues of confidentiality and potential liability complicate this practice. The Ophthalmic Mutual Insurance Company (OMIC) notes that online medical opinions may be considered “direct patient treatment” and recommends that interested physicians contact risk-management specialists for advice about “properly document(ing) your decision-making process and differential diagnosis, including the use of appropriate disclaimers’, as well as the applicability of state licensing requirements and whether they would be waived “when consultations are not delivered ‘live’”.7

Summary
These general recommendations are offered to guide physicians in the appropriate use of social media and may be used to fill gaps in state medical boards’ published guidelines. Physicians should adhere to appropriate standards of ethics and professionalism to maintain confidentiality and honesty and the public’s trust in our profession.

NANOS offers the following recommendations for how to be a positive influence in social media settings and to maintain professionalism:

a. Identify yourself and your qualifications
b. Identify why you are offering information and how it is substantiated
c. Be trustworthy, honest, and reliable
d. Provide knowledge and information that is useful and desirable
e. Share appropriately

Notes
1 Ahlqvist, T, et al. "Social media road maps: Exploring the futures triggered by social media". VTT Tiedotteita - Valtion Teknillinen Tutkimuskeskus (2454):13, 2008.
2 DeCamp, M. Social Media and Medical Professionalism: Toward an Expanded Program Arch Intern Med. 2012;172(18):1418-1419.
3 Laqu T, et al. Content of weblogs written by health professionals. J Gen Intern Med. 2008 Oct:23(10): 1642-1646.
4 Greyson, SR, et al. Physician Violations of Online Professionalism and Disciplinary Actions: A National Survey of State Medical Boards. JAMA. 2012;307(11):1141-1142
5 Summary of the HIPAA Privacy Rule
6 HIPAA Breach Notification Rule
7 OMIC: Policy Holder Services

Applicable Rules (from NANOS Code of Ethics)
“Rule 2.1. Professional Competence. The neuro-ophthalmologist must practice only within the scope of his/her training, experience, and competence. The neuro-ophthalmologist should provide care that represents the prevailing standards of neuro-ophthalmologic practice. To maintain this level of competency, neuro-ophthalmologists should participate in a regular program of continuing education. The neuro-ophthalmologist must not misrepresent credentials, training, experience, ability or results.”

“Rule 6.1. Public Communication. The neuro-ophthalmologist must represent himself/herself to the public accurately. He/She must not convey false, untruthful, misleading, or deceptive statements.  The physician must not omit material information without which the communication could be deemed to be deceptive. Communications must not appeal to an individual’s anxiety in an excessive or unfair manner and they must not create unjustified expectations of results. The neuro-ophthalmologist’s credentials, training, experience or ability must be accurately represented.  In no event should a neuro-ophthalmologist publicly use or otherwise disclose any patient's medical condition or treatment without the patient's prior written consent.”

“Rule 4.0. Conflicts of Interest. 4.1 The Patient's Interest is Paramount. A conflict of interest exists when professional judgment concerning the well-being of the patient has a reasonable chance of being influenced by other interests of the physician providing treatment. When a conflict of interest occurs or when one becomes apparent the treating physician has a duty to disclose such conflict to the patient.  The neuro-ophthalmologist must attempt to resolve any conflict of interest which arises to ensure that the patient’s treatment plan continues to service the best interest of the patient. If the conflict cannot be eliminated, the neuro-ophthalmologist must notify the patient of the specific conflict and, if the patient requires, terminate the physician/patient relationship. 4.2 Conflicting Ethical Duties. A neuro-ophthalmologist ordinarily must maintain the patient's confidentiality; however, if the neuro-ophthalmologist becomes aware that the patient intends to injure an identifiable third party, then the neuro-ophthalmologist must take reasonable steps to warn the third party or notify the appropriate authorities. Similarly, when the neuro-ophthalmologist becomes aware of the patient’s intent to injure members of the general public, the neuro-ophthalmologist must take reasonable steps to advise the appropriate public officials or agencies of the danger.  If the physician is uncertain of his/her duties he/she should immediately consult with the Ethics Committee.”

“Rule 2.3. Patient Confidentiality. The neuro-ophthalmologist must maintain the patient’s privacy and confidentiality and must comply with all applicable state and federal confidentiality rules and regulations.”

Other References
The HIPAA Privacy Rule, subsection on Research (45 CFR 164.501, 164.508, 164.512(i)) The Privacy Rule both permits important research and, at the same time, encourages patients to participate in research by providing much needed assurances about the privacy of their health information. For specific information visit the FTC’s Office of Civil Rights’ website (https://www.hhs.gov/hipaa/for-professionals/special-topics/research/index.html and/or consult your IRB.

“Principle 1. Ethics in Ophthalmology. Ethics are moral values. An issue of ethics in ophthalmology is resolved by the determination that the best interest of the patient is served.”

“Principle 7. An Ophthalmologist's Responsibility. It is the responsibility of the ophthalmologist to act in the best interest of the patient.”

American Academy of Ophthalmology Advisory Opinions of the Code of Ethics, Communications to the Public, Disclosure of Professionally Related Commercial Interests, Release and Confidentiality of Patient Records.

The Ethics Committee of the North American Neuro-Ophthalmology Society (NANOS) developed the North American Neuro-Ophthalmology Society Code of Ethics (the Code) to formalize the standards of professional behavior for all members of NANOS, regardless of the class of membership. The primary goal of the Code is to promote the highest quality of neuro-ophthalmologic research and patient care.

American Medical Association, Council on Ethical and Judicial Affairs Opinion 9.124 - Professionalism in the Use of Social Media. Issued June 2011 based on the report "Professionalism in the Use of Social Media," adopted November 2010. http://www.ama-assn.org/ama/pub/physician-resources/ medical-ethics/code-medical-ethics/opinion9124.page?
Accessed January 23, 2017.

The Federation of State Medical Boards, Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice, adopted April 28, 2012.

Bosslet, GT, et al. The patient-doctor relationship and online social networks: results of a national survey. J Gen Intern Med. 2011 Oct;26(10):1168-74.

Budd, L. Physician tweet thyself: A guide for integrating social media into medical practice. BCMJ. Jan/Feb 2013; 55(1):38-40.

Chretien KC, Azar J, Kind T. Physicians on Twitter. JAMA. 2011 Feb 9;305(6):566–8.

Collier, R. Professionalism: Social Media Mishaps. CMAJ. 2012 Sept; 184(12).

DeCamp, M. Social Media and Medical Professionalism: Toward an Expanded Program. Arch Intern Med. 2012;172(18):1418-1419.

Farnan JM, Snyder Sulmasy L, Worster BK, 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(8):620-627.

Greyson, SR, et al. Physician Violations of Online Professionalism and Disciplinary Actions: A National Survey of State Medical Boards. JAMA. 2012;307(11):1141-1142.

Greyson, SR, et al. Online professionalism investigations by state medical boards: first, do no harm. Ann Intern Med. 2013 Jan 15;158(2).

Laqu T, et al. Content of weblogs written by health professionals. J Gen Intern Med. 2008 Oct:23(10): 1642-1646.

McGowan, BS, et al. Understanding the Factors That Influence the Adoption and Meaningful Use of Social Media by Physicians to Share Medical Information. J Med Internet Res. 2012 Sep-Oct; 14(5).

Moorhead, SA, et al. A New Dimension of Health Care: Systematic Review of the Uses, Benefits, and Limitations of Social Media for Health Communication. J Med Internet Res. 2013 April; 15(4).

Mostaghimi A. et al. Professionalism in the Digital Age. Ann Intern Med. 2011; 154(8): 560-562.

Peregrin T. Time to tweet: social networking for surgeons. Bull Am Coll Surg. 2011 Feb;96(2):46–8.

Proposed by: NANOS Ethics Committee, January 2021
Approved by: NANOS Board of Directors, January 2021

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