How should physicians behave on social media?

Last week, Dr. Bryan Vartabedian (on Twitter as @Doctor_V) posted to his blog the narrative of a Grand Rounds presentation he gave in which he focused on the risks and benefits of physicians’ use of social media.

The post is long, but provides an overview of Dr. V’s approach to social media.  If you review his blog, you will see that this post (and the related presentation) neatly summarizes what Dr. V recommends as best practices to using social media.  I think it is a good read…but I do not agree entirely with his recommendations and conclusions.

I think it is easiest to start with the areas where I see that we are on common ground:

• I agree that medical care in the future will be a very different culture than it has been in the past.  Technology and patient empowerment have already changed the way we practice, and will continue to do so.  The e-patient movement and the interconnectedness allowed by social media will further encourage patients to find out about their own illnesses, research treatment options, and discuss these issues with their physicians in different ways than has been the case up until now.  Patients are already changing the nature of this dialogue, and health care will need to adapt accordingly.
• I also agree that the nature of social networks–varied sources of information, numerous perspectives, and various analyses–have changed the nature of how we receive information.  Many of us can recall recent major news stories that we first heard through social networks (Osama bin Laden’s death? Congressional budget deals adverting a shutdown?  Kim Jong-Il’s death?), both on the local and the national levels.  I learn about many developments in healthcare reform and clinical practice by following certain key accounts on Twitter: I see this information sooner than I would if I waited for traditional media or (gasp!) the evening news.  There is tremendous value to be found in using social media as a principle source of information.
• Those doctors actively engaging in social media are still the minority.  This is something that needs to change–as noted above, patients are already looking for information on the internet.  If physicians are not there, then we are missing out on being a part of this discussion.
• Finally, I agree that we must protect patient confidentiality and patient information–period.  I do not post/tweet about patients.  Period.  When I speak about “patients” (as I sometimes do on my personal blog) I speak in the aggregate, not as individuals.  Unless one has specific and direct permission to share an individual’s story, then it should not be shared.  I also agree that there is no acceptable way to practice medicine in any way on Twitter or via other social media.  Physicians can provide general information and/or point patients toward publicly-available resources (such as FamilyDoctor.org, or the Mayo Clinic patient information website), but we cannot and must not provide actual medical care via social media.

I disagree with Dr. V on some of his recommendations for how best physicians can properly use social media, though.  It might be that we see these issues from slightly different perspectives or through slightly different-colored lenses, but I think there is value in exploring the differences:

• The largest difference might be around our views of professionalism, and how these views might influence how we interact on social media.  Dr. V notes, and I agree, that separating one’s professional and personal presences online is an incredibly difficult task.  However, the sense I get from his blog post is that he favors restraint and that he favors limiting one’s online presence to that that would be in line with the most professional setting.  In other words, behave online at all times as you would behave in clinic.  This is doubtlessly a safe approach, but where does it leave our personal voices?  Can I discuss politics?  I wouldn’t do that with my patients, but can I do it here?  Can I post silly pictures of me at a gathering of friends, wearing a silly fake mustache and having a beer?  No doubt many of those following my account don’t really care about that photo, one way or the other…but is it unprofessional?  I wouldn’t post it in my office, but is it OK to share here?  Does this violate my professional role as a physician?  I use my accounts to discuss personal interests, not just medical issues.  Can I personalize my account–my voice–without being seen as unprofessional?  Does it make me less professional, or more human?  If I identify myself as both an individual and as a physician, is it wrong to express both aspects of who I am?
• Dr. V and I also differ on the role/value of anonymity online.  I would agree with him that we should not presume anonymity will actually protect us or our patients: I figure most anyone’s online pseudonym can be broken by someone smart enough and with enough time.  So I–personally–do not see the value in anonymity.  However, I do think there can be value in anonymity in certain cases.  What if a physician is criticizing the practices of a major insurer, or their employer?  What if someone wishes to discuss a sensitive personal issue without self-disclosing?  Even if this cloak of secrecy is not foolproof, it can provide a safer space for such discussions.  I think the content of an account will dictate whether or not it is trusted or considered valuable–not just whether or not it is anonymous.  I choose not to be anonymous, but that is my choice.  I can choose to ignore anonymous accounts…and others can do the same.  I do not think this is a one-size-fits-all situation, and I think individual users should have options as to how they can best and most productively engage.
• I have even suggested (in this post) that there can be value in anonymous, “unprofessional” conduct.  Whistle-blowers, agitators, and critics may all have important perspectives and contributions to an issue under discussion, or might call attention to larger problems.  Raising these issues might strike some as unprofessional…raising the question of who will decide professional vs. unprofessional conduct?

This is not to say that anonymity protects anyone’s privacy–it is a cloak, but one that can be removed with enough effort.  Anyone posting controversial or questionable material online needs to be aware of the potential consequences.  As Dr. V notes, doctors have lost malpractice suits, their jobs, and their licenses for posting material online that was sufficiently controversial or that violated patient privacy.  This risk is real, as is the risk that one could face sanctions from professional organizations.  The American Medical Association’s social media guidelines advise that, “[w]hen 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.”  The guidelines do not specify who “appropriate authorities” would be, but it could include hospital authorities, employers, or state-level Boards of Medicine.  There is need for physicians to be careful when interacting online, but this care is required whether one is posting anonymously or under their own name.

Take the @BurbDoc account, for example.  (Warning: this account is often not safe for work.)  BurbDoc posts anonymously, and criticizes much of what he (she?) sees in medicine–often with liberal use of profanity.  Many (most?) would consider this account unprofessional, and many are likely not fond if its existence.  My perspective on the account is that, although I do not personally appreciate everything that the account posts, BurbDoc has the right to post this material anonymously.  From following and interacting with the account, I feel that BurbDoc’s motivation to use social media comes from the right place: to expose inefficiencies and hypocrisy in medicine–especially on the part of insurance companies–of which patients might not be aware, and to discuss what they believe to be patients’ complicity in our dysfunctional system.  Personally, I could do without some of the language, and as a result I rarely share BurbDoc’s posts even if I agree with the sentiment.  But this is BurbDoc’s decision and his choice: he has chosen to use this approach, and he must come to terms with the fact that this choice might limit his audience and could create problems for him down the road.  Physicians who do not approve of this choice can simply choose to ignore the account; after all, BurbDoc does not claim to speak on behalf of anyone else.

I would argue that the best approach is more fundamental than the issue of whether or not we should be anonymous or whose definition of professionalism is most valid.  I think the best approach is this:

• Be nice.  Don’t be a bully, don’t be scornful, don’t be rude.  Be engaging and respectful.
• Be helpful.  When you have useful information or valuable insight, don’t be afraid to offer help or be a resource to the community.
• Be careful.  Remember, as Dr. V has said, that this is all happening in public.  Don’t say anything you would be afraid for others to see…and stand behind what you say.
• Be engaged.  Whatever your purpose for getting involved in social media, you should be here because you are looking to connect with others.  That means that you need to actually engage and connect with them.  Having an account that doesn’t interact with others has little value in my opinion.

I strongly agree with Dr. V’s call for physicians to become active in social media, both in this post in in this earlier post.  I have found there to be enormous value form my social media participation, and I do my best to add value.  But, I do not think that we need to separate or silence our individual voices to do this.  I think we can help each other be careful, and helping newcomers (or perceived outliers) stay out of trouble.  We’re all in this together, for our patients’ health and wellness.  But we are all human, and I think it is fair if our social media presence reflects that.

What will it take to get physicians using social media in healthcare?

(This blog was originally published on the Mayo Clinic Center for Social Media blog, 12/6/11)

——————–

Medical education is based on the foundation of science.  Undergraduate premedical majors are required to take a number of science courses in order to be considered qualified applicants for medical school.  Once in medical school, students are exposed through all four years to scientific research: we are taught about seminal basic science experiments that helped establish the biochemical mechanisms, and were are taught about the process of clinical research and how the scientific method has helped develop current medical treatments.

At the same time, as we are steeped in the tradition of science, we do not always do a good job of following the scientific method.  One of the greatest examples is the continued practice of providing antibiotic prescriptions for viral illnesses, despite the clear knowledge that antibiotics will not affect how quickly patients improve.  Even though we are trained to approach questions from the scientific perspective, human nature can impact how reliably we follow evidence-based, scientifically-grounded recommendations.  Often time, the rationales given include either the fact that one might be uncertain about the nature of the illness being treated and/or the claim that patients expect antibiotics and that it is easier (and more customer-friendly) to just give patients what they expect as opposed to standing by the evidence.

The truth is that medical practice is a combination of science and human nature.  Hopefully we lean towards the evidence more often than not, but you cannot deny the human part of the process.  Add in the fact that many physicians are employers, small business owners, and breadwinners, and the balance can become more complicted.  As a result, many of the decisions we make are based on considerations from both sides of the issue.

I believe that this will also be true of efforts that attempt to engage physicians in communicating via social media.  To date, efforts to encourage physicians to engage in social media because it is interesting, fun, etc do not seem to have much traction.  I propose that it will require showing that social media has measurable benefits to patient care (scientific argument) and that it improves practice efficiency and/or practice income (human nature argument) in order to increase physician engagement.

• If research programs that are well-designed, double-blinded studies investigate whether various approaches to social media engagement improve patient outcomes of some sort (disease-oriented outcomes like blood pressure or diabetes control, patient-oriented outcomes such as a global measurement of wellness) and show a beneficial result, then we will have scientifically-based evidence showing that social media can improve healthcare.  This will appeal to our self-perception as scientists.
• At the same time, if it can be demonstrated that using social media improves how medical practices work (fewer calls back, more new patients, more satisfied patients, etc) and if they can increase the efficiency of medical practices (thus reducing costs), then we will have information that impacts the human nature side of the decision: physicians will have more profitable practices, or will be able to hire more staff, or will be able to offer additional services to their patients.  This appeals to the business/professional side of a physician’s worldview.

Needless to say, these two goals are not mutually exclusive.  Often times, interventions that improve medical outcomes also improve practice efficiency…and could become more important as medicine moves towards paying for quality of care as opposed to intensity or quantity of care.  But I think it will take arguments that satisfy our scientific training as well as business needs that will increase physicians’ involvement in social media.

Society of Teachers of Family Medicine Conference on Practice Improvement

I mentioned in my last post that I was presenting on social media at a conference…below, I’ve embedded the link to see the slides Ben Miller and I used.

 

How Twitter Enhanced My Conference Experience

Over time, this blog has been focused on when, how, and where social media (SocMed) could impact healthcare. THis time, I am writing a short post focused on another benefit that has arisen out of social media engagement.

I am currently in California, attending the Society of Teachers of Family Medicine (STFM)’s Practice on Conference Improvement. I don’t have any personal connections with this part of the state, and given the conference’s location in a tourist-focused area there is not much here for me to do outside the meeting. To be honest, I would never have come here if not for this conference. Normally, then, all I would have done would have been to attend the meeting sessions, and then spend a lot of time in my hotel room. I’m fairly bad at mingling, networking, and the like.

This time, though, I mentioned on Twitter that I was coming here. As a result of my ongoing conversations on Twitter–whether in the context of organized Twitter chats, or on the fly–folks in the area contacted me to meet up in real life.

Ben Miller (@miller7) and I co-presented a talk on SocMed at this meeting, so we met up on arrival. Of note, Ben and I met on Twitter, and our ongoing collaborations (talks, the OccupyHealthcare Project, etc) grew out of our SocMed connection…before we had ever met in person.

During the first day of the meeting we met Jay Lee (@FamilyDocWonk), someone we had both been in touch with for nearly a year online. Jay joined us later that night for a tweet-up with Gregg Masters (@2HealthGuru) and Fred Trotter (@FredTrotter) during which we spent a lot of time discussing the nature of the OccupyHealthcare movement…and brainstorming how each of us can contribute to the cause.

This morning, Jay met Ben and I again as we were joined by Mark Harmel (@MarkHarmel). Mark is a photographer and an MPH student, and we had an active discussion abthat opportunities to participate in healthcare reform and system redesign.

Ben, Jay and I went to lunch together, joined by faculty and residents from the residency program where Jay teaches and practices. From this meeting I might have found a resource to help identify physicians who can help in the international healthcare project I help lead.

Finally, tonight Ben and I are having dinner with Carmen Gonzalez (@crgonzalez). I have shared this blog with Carmen and Mark Dimor (@MarksPhone), and have not met either of them in person. I’ll finally remedy that…halfway.

Before I was involved in SocMed, this meeting would have been ho-hum…if I had come at all. Now, I can say that I have met new real-life friends, have strengthened ties with others, and have made connections and discussed new projects that will keep me busy–and thinking–for some time.

One of the criticisms of SocMed is the belief that connections made here are broad, but shallow. I would argue that the breadth of the connections we make via SocMed allows us to interact with people we would otherwise never meet, and that these interactions can develop into meaningful collaborations and friendships.