Guiding Principles for Physician Use of Social Media

March 13, 2012

“Art is not a mirror held up to reality but a hammer with which to shape it.”  — Bertolt Brecht

In two prior posts, I have discussed the issue of professionalism and social media.  These two posts can be found here (professionalism) and here (physician online behavior).  I have also taken issue with medical organizations’ extant social media guidelines.  In some of these posts’ comments, it has been noted that there is no corresponding guideline or document that expressly discusses appropriate, positive use of social media in health care communications.

As a result, I am taking the liberty of making some suggestions as to what I think are important guiding principles for effective physician use of social media.  This will include some cautions that I feel are especially useful, but I would also like to explain how and why I think physicians can use social media in positive and useful ways.

Part of this task includes defining physician professionalism.  There are various definitions (click here for the first defintion, click here for the second definition, and click here for the third definition), but they share the common themes of respect for patients’ autonomy, individualism, and privacy; response to and concern for societal needs; embodiment of humanistic values of altruism, empathy, compassion, honesty, and integrity; focus on the scientific basis of medical knowledge; accountability to peers; and commitment to professional development and competence

With those guiding principles, here are my suggestions for how physicians can effectively use social media:

  1. Do not discuss patient’s illnesses, medical conditions, or personal information online.  Unless you have a patient’s express permission to share their information, then do not discuss anything about them online.  The simple fact is that even if we believe we have made information anonymous, it is hard to do so completely (as this doctor discovered).  If a patient has given you their permission, make that clear in the post.  Otherwise, do not discuss real patients’ information via social media.  Rather than choosing to discuss a specific recent case that you might have seen, it would be better to offer a broader perspective or discussion on the issues at hand.  This is especially true in a smaller community, where even broad descriptions of patients and clinical situations might allow patients to be identified.
  2. Use social media to share information that promote quality health care and up-to-date medical information.  There is a wealth of information available on Twitter, for example, that provides current information regarding medical research and treatments.  The New England Journal of Medicine, the Journal of the American Medical Association, the American Academy of Family Physicians, the National Institutes of Health, and the Centers for Disease Control (among many, many others including individual medical specialty organizations and journals) all have accounts that provide regular updates with a focus on basic science and clinical care.  By following these accounts and sharing relevant and actionable information, we promote its dissemination.
  3. Address those societal needs that you think are most important, or that motivate you.  Social media use will undoubtedly be an added responsibility during your free time, and so using it to focus on issues that are relevant to you makes it easier to sustain the effort.  For example, I am a strong believer in the need to enhance our primary care workforce via family medicine and I support the Patient Protection and Affordable Care Act (PPACA) of 2010.  As a result, my Twitter feed focuses on these topics.  I share updates about how the PPACA will enhance patients’ access to health care and reform health insurance company practices, about the importance of family medicine (and primary care) and the need to reform our system to support and train more family physicians, etc.  Each of us will be motivated by our specific interests, but we should use social media as tool to call for necessary change to benefit society as a whole.
  4. Recognize that you represent your profession, and help others recognize that they do, too.  When someone views your social media posts, they will likely see the post through the lens of your profession.  If they see my posts, it might not be seen as “Mark Ryan thinks such-and-such” but rather “Dr. Mark Ryan thinks such-and-such.”  It might then be tempting to presume that others in the same profession feel the same.  So, take care not to post updates that would violate the definition of professionalism identified above.  If you see someone else posting updates that seem unprofessional, I think it is appropriate to connect with them and discuss this issue–not in a punitive way, but rather to help promote the proper use of social media tools.
  5. Promote the humanistic values identified as congruent with medical professionalism.  Be honest, forthright, helpful, and compassionate.  Offer help, answer questions, and suggest resources when you are able to do so.  Be open to contact from others, and participate in discussions when time allows.
  6. I do not think it is necessary to separate personal and professional content online.  My social media presence is a reflection of who I am, and expresses my beliefs and my priorities.  These are what make me the person and the physician that I am, that define the societal needs that I seek to address, and determine my perspective on any number of issues.  To be personal, my social media presence must reflect my beliefs.  However, I do use a disclaimer to note that my opinions are mine alone (not those of my employer), and I understand that there are those who will disagree with me.  Social media is an opt-in phenomenon: if someone wants to read my opinions, they will have to come find my accounts…and they can choose to ignore me and any of my posts.
  7. I do not think we must keep our social media content locked behind tight privacy restrictions.  My accounts’ privacy settings depend on my anticipated use: I keep my Twitter and Tumbr accounts public because I intend for the information to be public.  I keep my Facebook account private because I do not intend to use it for public information, but rather to keep up with friends and family.
  8. Do not practice medicine via social media.  It seems self-evident, but it is worth making clear.  I do not provide any individual, specific medial care or medical advice via social media.  The most I have done is to provide links to already-available online resources for people to review and to help them make their own decisions as to how to proceed with any given medical issue.  I do not knowingly interact with any patients on Twitter but, if I did, I would interact with them the same way I interact with anyone in a public setting.  I do not friend patients on Facebook because of how I choose to use Facebook
  9. Presume that everything said online can be found if someone looks hard enough, and is going to be available forever.  This might be an exaggeration, but it provides guidance when thinking about what information should be shared.  I assume that nothing is actually private, and so I do not post any information (even via direct messages) that I would be bothered if it were made public.  For the same reason, I choose not to use any anonymous accounts: I assume that someone out there could identify me if they tried hard enough.  This helps me edit what I put online and what stays in my head.

I hope that this post accomplishes its goal: to provide some suggestions and guidelines on how to use social media effectively and professionally as a physician.  Social media is not simply a way to reflect what is happening around us, but rather a way to play an active role in changing society for the better.

Please provide comments and suggestions below.


Is That An App Or A Medical Device In Your Pocket?

August 23, 2011

At a recent Twitter chat of the Health Care Communications & Social Media group ( see the August 21, 2011 chat ) , one of the questions considered by the group prompted a heated discussion over the province of  the U.S. Food and Drug Administration (“FDA”) to regulate phone/iPad applications. For the uninitiated, there have been a slew of new apps that have entered the market, some of them approximating medical devices, while others have merely added to the wellness and personal diary category.  The growing sophistication of the apps into the medical device arena has prompted the FDA to develop a draft guidance to provide oversight and regulatory clarity.

During the Twitter chat mentioned above, some individuals thought the FDA’s action was intrusive and would stifle innovation. Given the potential for economic benefit in the growing health care field, I doubt this concern holds too much water. The fundamental issue at play here is if the app itself is a medical device. In section IV of the draft guidance concerning the rule’s scope, the FDA states that this concerns mobile medical devices defined as those app which:

  • are used as an accessory to a regulated medical device; or
  • transform a mobile platform into a regulated medical device

This was also affirmed by the FDA during its July 19, 2011 Twitter chat on its new draft guidance:FDA mobile device definition

The FDA goes on to say what its rule does NOT cover. I am paraphrasing below, but if you read the scope itself , it provides good examples in defining these exclusions: 

  1. apps that are copies of medical books, texts, or teaching aids (e.g. Physician’s Desk Reference or flash cards)
  2. apps that only log, record, offer evaluations or suggestions on “maintaining general health or wellness”
  3. apps that automate general office operations (billing, inventory, appoitments, insurance transactions, etc.)
  4. apps that are general tools and NOT marketed for a particular medical condition (e.g. an audio recording or note taking pad)
  5. apps that serve as electronic health records or a personal health record system

 A lot of the hubbub during the Twitter chat concerned stifling innovation in this burgeoning space. However, what many in the group did not recognize is that we already rely on the FDA to regulate medical devices, so as technology changes and encompasses apps, so too must the FDA’s purview of these tools.  A cursory look at some apps makes the FDA’s interest valid:

Smartheart: This is being represented by the manufacturer (SHL Telemedicine) as a self-service heart monitor, and as the smallest ECG. It operates by performing an electrocardiogram and allows the user to send the reading to his doctor.

IBG Star Monitor App: This involves an iPhone, an attachable iBGStar device, and the iBGSTar Monitor App. When used in concert together, the system allows patients to test their blood sugar wherever they are, record notes and send the data to their doctors.

diabetes-meter-iphone-app

Fujifilm Synpase Mobility: This app allows doctors to view radiology films in 2D, 3D and to use MIP/MPR as in a clinical setting from Androids, iPhones, and iPads.

Reliance on any of these tools to diagnose or treat patients makes them clearly medical devices, and well within FDA’s control.  What is still up in the air are those “wellness” apps that happen to encroach into the clinical space and are used to diagnose and treat patients. I posed that question during the FDA’s July 19th chat on Twitter concerning their new draft guidance:

Question to FDA regarding pedometer as a clinical device

FDA says: We'll get back to you on the pdeomter question

I’m still waiting. And therein lies the ambiguity that will beset developers as they race to market. Will they have to submit their apps for approval as a medical device? For the wellness apps that could be used as clinical instruments, the guidelines might not be precise enough. In the example I was thinking of I imagined a pedometer as part of an obesity treatment (exercise aid) or as part of an obesity clinical study where exercise logging was a requirement or an outcome. Plus there’s the issue of the long slogging process of device approval, involving clinical trials. Granted the process is important to ensure safety, but I openly wondered if a shorter path is possible.

Question to FDA on shortening the clinical trial process for apps

I am still waiting on that too. While the FDA sorts all this out, you are invited to offer your remarks at the FDA’s website where it is gathering public comments. Join in to get the last word. By the way, the docket number for this is FDA-2011-D-0530-0002 and at Regulations.gov you can enter your comments electronically.

FDA invitation to 1.usa.gov/MobMed


More Social Media Guidlines for Physicians. Should We Care?

July 17, 2011

Late last year, the American Medical Association published guidelines to guide how physicians use social media.  Once the recommendations were made public, I posted that I did not think the guidelines were very helpful.  My overall sense was that the guidelines were designed more to discourage or limit physicians’ participation in social media…or at least highlight the risks of using social media.

Now, two other sets of guidelines have been released.  The Massachusetts Medical Society (MMS) released their guidelines about two months ago, and the British Medical Association recently made their guidelines public.

I’ve been meaning to review the guidelines in detail, but have not had the time to do so.  So I thought I would try and give an overview of where the guidelines are similar and where they differ.

Highlights of the MMS guidelines include:

  • Patient privacy is of the utmost importance.
  • Physicians should maximize privacy settings, but should not assume these settings are absolute.
  • Physicians must maintain professional boundaries if interacting with patients online.
  • Physicians should separate personal/private and professional information online, and should not connect with patients in public social media settings.
  • Physicians should be responsible for monitoring others’ use of social media: “when physicians see content posted by colleagues that appears unprofessional, they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.”
  • Physicians should disclose any relationships they have with any services or products that they review or discuss online.
  • Physicians must realize that any information posted online may affect how the public views physicians and the medical profession, might impact individual physicians’ reputations, and may have career consequences (especially for trainees).

I do not believe that these guidelines differ very much from the AMA guidelines I mentioned earlier.

Meanwhile, the BMA guidelines largely tread the same paths: protect patient privacy, disclose conflicts of interest when they exist, be aware of how your online posts and comments might reflect upon yourself and the medical profession, etc.  The BMA also specifically notes that “It would be inappropriate to post informal, personal or derogatory comments about patients or colleagues on public internet forums.” Of note, the BMA does not suggest that physicians should be responsible for policing each others’ online posts.

As was the case with the AMA guidelines, the BMA guidelines also emphasize the potential harms and risks of physician involvement in social media.

Maybe this is the nature of guidelines: to highlight how potential risks without focusing on the potential benefits.  But none of the guidlines–AMA, MMS, or BMA–discuss how to use social media effectively and successfully.  If physicians are only provided with cautions and warnings about social media, and are not given guidance on how social media can be used to enhance the health of individuals and communities, then physicians are hearing an unbalanced perspective.

In fact, some physicians have argued that health care professionals have an obligation to engage in social media: read Brian Vartbedian (@Doctor_V)’s perspective here, and watch a video of Dr. Wendy Sue Swanson (@SeattleMamaDoc)’s thoughts here.

So: on the one hand, physicians are called to engage with patients via social media.  On the other hand, professional organizations continue to urge physicians to exercise caution and care without discussing possible benefits and values of engaging with patients via social media.  So what do we do?

My thoughts: I put very little weight on these guidelines.  The AMA, MMS and BMA guidelines all tend lack specifics, and many of the cautions seem to be self-evident.  Responsible, professional physicians should not disclose patients’ private information while using social media, and responsible, professional physicians should be aware of the limitations of online privacy.  So long as a physician is using their common sense, then these guidelines offer little guidance.

So: I will continue using social media and I will continue encouraging fellow physicians to use social media.  I believe the value outweighs the potential risks, and that reasonable caution provides sufficient protection.  I will continue to look for guidelines that offer guidance an insight in the positive sense (how to get the best results and value from using social media) as opposed to only offering warnings and cautions.  Until those guidelines are released, I will continue to put very little weight on social media guidelines for physicians.


How Useful are the AMA Guidelines on Social Media and Physicians?

November 28, 2010

A few posts ago, I noted that the AMA had released guidelines regarding how physicians should use social media.  I noted that I would try to find the full guidelines and return to discuss in more detail.  I was surprised when I actually saw a copy of the new guidelines, mainly because the actual policy is not all that much more detailed than the initial summary.  In essence, the guidelines advise physicians to ensure both patients’ and physicians’ own privacy, maintain appropriate doctor-patient relationships and act accordingly to professional standards, to monitor and address on-line information posted by colleagues, and to remember that any information one posts on-line may have an impact on one’s professional career.

A few colleagues have already posted about the guidelines, and they had different perspectives.  Jane Sarasohn-Kahn of the Health Populi blog and Ted Eytan, MD both felt the guidelines were useful.  Health Populi notes the AMA’s late arrival in this area, but welcomes the early steps of promoting and guiding physician engagement with patients via SM.  Dr. Eytan highlights some issues with the guidelines but feels that they will be useful in promoting discussion and dialogue between physicians and patients regarding SM’s role in health care.  On the other hand, the ScienceRoll blog was unimpressed, pointing out how general the guidelines are and the lack of specific recommendations that might have been included.  That post’s author believes that these guidelines are nothing more than publicity on the AMA’s part, and that they do not provide any true value.

The #hcsm Twitter chat participants discussed the guidelines on November 14.  The overall tone of the discussion was one of being generally unimpressed that the guidelines would have any great impact, yet hopeful that the guidelines may help further discussion and debate.  No-one seemed to feel that the guidelines suggested any sort of turning point on SM use in health care.  The only new element introduced in the guidelines is the recommendation that physicians should police each other’s SM postings and take action if inappropriate posts were noted–either by discussing with the posting individual or by reporting the individual to the necessary authorities.  These element created more discussion than some of the others, but even here the guideline is so vague that its actual impact is difficult to assess.

My take on the guidelines are these:

  • First, these guidelines don’t really make much of a difference in my use of SM.  Anyone who has been active in discussing SM use in health care or by health care providers has already seen these proposals and suggestions multiple times.  For anyone active in the #hcsm or the #MDChat Twitter conversations, these guidelines largely repeat ideas already discussed and conclusions already reached by many (most?) of those already using SM to promote health care communications.
  • Second, these guidelines are not practical or concrete enough to provide protection for MDs using SM.  If a patient or a colleague complains about what I post on-line, I would be hard-pressed to point at the the AMA’s guidelines and prove that I have not done anything wrong.  These guidelines do not provide any sort of “safe harbor” criteria, which could provide cover for a physician who had used SM in the “right” way.  This lack of detail or of specific examples means that I cannot be entirely sure that my posts will meet (or fail) the AMA’s test of appropriate use.
  • Third, the idea that physicians should “police” risks alienating physicians from using SM.  If I feel that part of my job is to keep an eye on my colleagues’ posts (and to take action if I feel they have posted something “that appears unprofessional”), I might be less interested in seeking to engage with other docs via SM.  The guideline’s lack of specificity is also worrisome in two specific ways: 1) How does one decide if a post “appears unprofessional”?  This standard is worthless to anyone trying to judge another person’s post.  If I post about my dinner, is that “unprofessional”?  If I criticize the AMA, is that “unprofessional”?  There is no final arbiter on this issue, so in theory any post could “appear unprofessional”.  2) If a physician notices a post that is later judged to appear unprofessional and that physician did not take action, could there be sanctions or other harms as a result?
  • Fourth, I think these guidelines may have a role in beginning the SM discussion at a formal level.  As vague as they are, they present a framework which can then be further developed and fleshed-out by the AMA or by other organizations.  The more engaged we are in the process as physicians, patients, and advocates, the more useful the guidelines may become.

If these guidelines are looked upon as the final word, they are clearly insufficient and could lead physicians to avoid or reduce SM communication even as patients are turning to SM more and more.  If it stops here, the AMA may have harmed the process of physicians exploring and incorporating SM as a valuable way to communicate with patients and peers.  As they currently stand, the guidelines do not advance the idea of SM in health care communications in any way.

However, if the AMA reads posts such as this, speaks with physician members and patients, and revises the guidelines to make them more useful and more valuable (creating guidelines that could be used to establish “safe harbor” use of SM, and clarifying when/how physicians should address other people’s posts), then these guidelines could be seen as a first draft of useful and effective SM guidelines that could benefit physicians and patients alike.


AMA Social Media Guidelines

November 9, 2010

The American Medical Association has issued new guidelines intended to help physicians use social media (SM) safely and appropriately.  The initial press release is online.

 

The key points in the new guidelines appear to be in agreement with much of the HCSM discussion online and with previous posts and discussions on this site: be professional, be careful, be private when necessary (both with one’s own information and always when discussing issues with patients).

 

My one concern is the recommendation that physicians monitor their internet presence and make sure information is accurate and updated when necessary.  This is easy enough for sites we might use regularly (blogs, Twitter, etc) but will be much more difficulty when dealing with physician rating sites and the like.  How much time would that require?

 

I intend to look for the full policy document.  We will post and address here once we are able.


Rules for Successful Health Care Social Media Interactions

October 7, 2010

1) Be respectful

 

2) Be helpful

 

3) Be careful regarding personal health information privacy issues

 

4) Listen as much (or more) than you speak.


Let’s Be Good Social Media Neighbors

October 7, 2010

While social media offers great potential in health care–there are already some early positive results in providing direct medical and fiscal benefits to individuals and organizations—it also brings new concerns and new responsibilities .

At the same time, these opportunities open up new concerns and new responsibilities.  SM thrives off of positive interactions, which means that those who are involved must develop the necessary skills to contribute to the discussion.  These skills include an ability to engage in discussion without triggering arguments, a willingness to help others when necessary, and an understanding of the value of linking people with similar interests who might not otherwise connect with each other.  There are also concerns about privacy–both in terms of one’s personal information as well as one’s specific health issue disclosure.  These topics were discussed during October 4th’s #hcsm chat.  In my mind, this is similar to learning how to be a good neighbor, and find ways to be friendly and helpful, engage in good productive discussions, and share appropriate information.

The first part of the #hcsm chat focused on whether SM social skills are learned or whether they are born of common sense.  I strongly believe that these skills are learned by observing and listening to other (more experienced) SM users and by becoming more active and vocal as one gains more confidence.  Personally, I have learned much about being a good SM citizen through interacting on the #hcsm chats and from online exchanges with individual SM users.  I also think a certain amount of common sense is involved, but the SM environment can be daunting for new arrivals who may need some guidance or advice to find their footing.  As @MeredithGould noted, though, “‘Common sense’ doesn’t exist without a moral compass to guide behavior re: protecting/respecting privacy.”  Experienced SM participants can help model proper behavior for newcomers who may make errors of omission or commission.  This seems to summarize the consensus: common sense courtesy and respect is a necessary starting point, with the finer (and necessary) details of SM social skills being passed along to newcomers as they become more active.  Without good SM social skills, conversations and discussion rapidly devolve into arguments and much of SM’s potential can be lost.

There was also a sense that SM veterans can help newcomers avoid making mistakes that have been made before.  @doctoranonymous commented that “All the social media skills Ive learned were through all the social media mistakes I made,” while @drseisenberg noted that “A social media master is one who has made every mistake possible in social media.”  Clearly, there can be a steep learning curve, and part of being a good SM neighbor is helping others avoid known pitfalls such as inadvertently publishing personal private information or sending out excessive or offensive messages.

Privacy is another issue that needs to be addressed in SM–both privacy about oneself and privacy about others.  On the one hand, we might not want to reveal too much about ourselves in SM settings.  On the other hand, some SM partcipants must ensure they are protecting the privacy of others, such as health care providers protecting patients’ information in compliance with federal law (HIPAA).  Similarly, attorneys who use SM must take care not to divulge confidential client information.  Other information might not be legally protected in the same way, but still is not appropriate for a public discussion, e.g. revealing a friend’s medical condition would be morally suspect.  While there are bright legal lines in some cases, a good deal of our sense of privacy is somewhat generational, with younger SM users more willing to make personal information public.  My sense is that as a medical professional I must abide by the most stringent standards in place and therefore I avoid posting any private information that could be patient-related.  At the same time, I do not post much personal information about myself.  I presume that if I post something online, it can be found if someone looks hard enough.  Therefore, if I do not want my information to be public than I need to keep it offline.  For me, this means I don’t identify my family, address, employer in public SM settings, and I do not discuss any specific patient issues online.  Other participants felt similarly: @lisastockwell: “You have to assume SM is a public conversation and act accordingly. Same rules apply to conv. you have in a packed waiting room.”

Some of the actions we can take to protect privacy may seem like common sense, but there is still a need to ensure that SM users are aware of the necessary steps to protect both their own information and that of others.  @OSUSquire wrote “I also think that schools, from elementary to med schools, need to be teaching responsibility around digital tools.”  Likewise, @macobgyn discussed how he “spoke at a middle school last wk about STD/pregnancy privation and included sexting and responsible Internet behavior”.

[An aside: the privacy issue brings to mind a topic from the September 20th #hcsm, in which the discussion topics included whether health care providers and/or patients have a right to privacy and anonymity online.  I refer you to that chat summary for now; I hope to address it again in the future.]

We must not presume that SM users–especially new SM users–know all the etiquette and common practices involved in SM use, and we cannot expect SM users to recognize all the ways in which private and personal information can be disseminated online either.  As established SM users, those of us who are already involved should help pass this information along to those who need guidance.  For newcomers, they need to remember a few crucial approaches to engaging in SM:

1) Be respectful

 

2) Be helpful

 

3) Be careful regarding personal health information privacy issues; and

 

4) Listen as much (or more) than you speak.

With these common-sense suggestions and some experienced guidance, newcomers and veterans alike may speed the real promise of using SM for better health care.


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