In a short period of time social media has grown to have a significant impact on all our lives, but doctors face particular professional and personal challenges when negotiating the online world. David Lynch investigates
In recent months the ‘old media’ printing presses have been rolling in the US, UK and Ireland. Leading doctors’ organisations in all three countries have published guidelines for members on how best to conduct themselves on ‘new media’ – particularly the social kind.
There is much optimistic talk to be found within the pages of the guidelines, celebrating the benefits of social media. These include the opportunities to interact with fellow professionals across the globe or the ability to use the net as an educational tool.
But much of the focus on the guidelines has been directed towards the pitfalls and ethical dilemmas faced by doctors online. Doctors have to deal with some tricky problems – such as what to do when a patient wants to become your ‘friend’ on Facebook? Or whether it’s ever appropriate to provide medical advice by email or text?
In the US, both the American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB) have only recently issued guidelines to doctors. Among their recommendations are that doctors should not friend or connect with patients online. The ACP also tells members that they should avoid using texts for medical interactions. Interestingly, the ACP recommends that doctors should establish a professional profile that will show up first on a search engine so doctors can attempt to control their image and reputation online.
Across the water in Britain, the General Medical Council (GMC) guidelines on how UK doctors should use social media came into effect in April. The guidelines emphasise the need for patient confidentiality and insist that despite the novelty of social media, “standards expected of doctors do not change because they are communicating through social media rather than face to face or through other traditional media”.
“Using social media has blurred the boundaries between public and private life, and online information can be easily accessed by others,” say the GMC guidelines.
“You should be aware of the limitations of privacy online and you should regularly review the privacy settings for each of your social media profiles.”
Back in Ireland, IMO members passed a motion at the 2012 AGM calling on the union “to develop guidelines on the ethical usage of social media”. The result is the IMO position paper on social media, published in April this year. The Irish union also recommends that doctors avoid accepting patients and their relatives into social networks.
Immediate
Separately, social media has sparked some interesting developments within doctors’ organisations. When the IMO released a statement last month updating members on how talks with the Labour Relations Commission were developing, it led to some instant reaction from doctors on Twitter. Rather than ignore the queries or concerns, IMO Industrial Relations Director Steve Tweed directly engaged with the doctors online. This type of instant interaction between union leadership and members could not have occurred before recent social media innovations. Members would have had to wait until a branch meeting or an AGM to make a point.
Social media has increased access, and more crucially, an expectation of greater access among users. This expectation goes far beyond this inter-union case. Patients often also have an expectation of greater access to their doctor, and this is where problems can arise. The doctor/patient relationship has long been based on trust and strict professionalism. But now that this relationship has migrated online somewhat, doctors face new challenges.
By their very nature organisations react slower than individuals. So while internationally the major doctors’ organisations are only now publishing social media guides, many doctors have been engaged online for years. Of those contacted by Medical Independent (MI), it is clear that most have thought deeply about their online conduct as a doctor.
Social media can prove a great way for doctors to remain professionally connected. Of course, as with any cutting edge technology, there is a generational aspect to the adaptation. For NCHDs and medical students, social media is something that is very familiar. For older doctors, all of this online innovation can prove a little more daunting.
Irish doctors
An increasing number of Irish doctors have thrown themselves into the world of social media. Some have established blogs, others have professional Facebook accounts. The favoured social media platform for doctors is undoubtedly Twitter, where some Irish doctors have already garnered a large number of followers.
There are international medics who have accumulated tens of thousands of followers, and while Irish doctors have not reached those numbers, some have already picked up thousands.
For instance Consultant Rheumatologist Dr Ronan Kavanagh has over 3,000 followers to his Twitter account and is an influential blogger. Dr Niall Crumlish is also among the most active on Twitter, with over 700 followers. The psychiatrist is also a music journalist, but he first ventured online just to “follow people and organisations who I find interesting,” he told MI.
Those initial tentative steps into the ‘Twitter world’ have now been replaced by confident strides across the social media arena.
“As time has gone on I have been more active as a tweeter rather than a consumer of other people’s tweets, but I follow way more people than follow me because I’m (a) not that interesting and (b) more interested in what other people have to say than in what I have to say.
“I am both a psychiatrist and a music writer and there is abundant discussion both of music and of mental health on Twitter.
“I think it has helped my work as a psychiatrist because I am automatically exposed to so much discussion about psychiatry, and these are interesting times for psychiatry. I’ve come across research and perspectives that I may not otherwise have come across.”
Dr Crumlish said that online interactions can often lead to positive experiences in the “real world”.
“The conversations you have on Twitter sometimes have real-life results. About three weeks ago I was involved in a Twitter conversation about the law around involuntary admission under the Mental Health Act 2001... That conversation evolved into an opinion piece in The Irish Times.”
However, as anyone who has any experience on Twitter knows, there can be quite a few sharp elbows thrown around and it can get bloody online.
Dr Crumlish says he has experienced no major negative incidents online, but he still sounds a warning to doctors who are active tweeters.
“Twitter is, at its heart, a 140-character medium. It is not a place for nuance and it is a place where people with fundamental disagreements bump up against one another; those disagreements rarely get resolved.
“Without looking too hard you can find any number of highly emotive exchanges about all kinds of things, including psychiatry.
“Twitter disagreements can get personally hostile quickly. Doctors need to stay out of that.”
Twitter disagreements can get personally hostile quickly. Doctors need to stay out of that
In terms of the important issue of doctor-patient interactions online, Dr Crumlish is clear in his standpoint.
“Doctors shouldn’t interact with their patients online. Doctors should be readily available to their patients, but not like that.
“Social media is not a space for the doctor-patient relationship. The IMO and GMC guidelines are both clear on that.”
Dr Paul Carson is a Dublin-based GP who is also author of a series of best-selling thrillers. It is this life as a successful novelist which has brought him into the world of blogs and Twitter. However, he does have some thoughts on how social media interacts with the medical profession.
Dr Carson began an online presence “only to promote my work as a writer of thrillers. It’s had no impact (that I know of) on my medical career,” he told MI.
Caution
When asked how doctors should interact with patients through social media, he has clear advice.
“With extreme caution. Diagnosing/treating based on online chats/consults is a minefield of potential mistakes and litigation,” he warns. “Misinterpretation of comments can also be a potential pitfall.”
Dr Carson thinks doctors online should proceed with care.
“Properly handled, taking care of what you write – never write when drunk, overwrought or angry – and knowing your audience, are my only tips.
“Social media is here to stay and (as usual) doctors are the last group to catch up with and use this powerful tool to their advantage.”
However, it seems that the importance of social media is garnering more interest from some doctors.
Dr Alan Coss, Consultant Gastroenterologist in Galway, has an active Twitter account. When contacted by MI, he had recently returned from the world’s largest annual meeting of gastroenterologists in Orlando in the US.
“For the first time, as far as I know, the meeting included a session on social media and related technological advances in GI practice,” he said.
“The various speakers highlighted the increasing importance of doctors engaging with social media on a professional level.
“Also, a brochure was given to all attendees on how to use social media to interact with fellow attendees and colleagues who were unable to attend. So clearly the major medical societies are aware that social media is more than just a fad.”
Over the last three years Dr Coss has become more active online.
“In particular, I have been using Twitter more and more, and it has had a hugely positive impact on my work,” he said.
“By following the Twitter accounts of major medical journals, societies and leading international specialists, I regularly receive brief updates on new research and advances in clinical practice.
“The fact that the information is delivered in little snapshots means that I can incorporate it seamlessly into a busy working day. Links and related articles are saved for more detailed reading when time permits.
“It was only recently, when I thought of it, that I realised that Twitter is now my primary source of medical information and updates.”
Educational
There are other doctors who see social media primarily as an educational tool and use it to develop this area. Dr Andy Neill is one of the webmasters behind the educational website emergencymedicineireland.com.
“Social media has always been about medical education for me and I spent a year or so as a consumer of various online social media educational resources prior to starting a website of my own, and joining and becoming active on Twitter,” Dr Neill told MI.
“At the time I was in a full-time teaching job and it was a great way to keep in touch with what was happening.
“I remain on social media for the wonderful educational material, experiences and the opportunities it has given me to develop my own teaching.
“I tend to liken social media to one continuous, online medical conference. As odd as it may sound, all the same things, like education, networking and inspiration that you find at a good medical conference, can be found online.
“I have no doubt I am a better clinician because of what I have learnt online. Emergency medicine is a small community and there are only so many learning opportunities. Those opportunities are vastly increased by online education.”
There are many locations online where doctors can continue to develop their skill set. For instance Med iLearning (www.medilearning.ie) is an independent, Irish-based website, (owned by the publishers of MI) intended to assist Irish doctors in meeting their personal learning CPD responsibilities.
Dr Neill describes his experience online as having been largely positive, but he understands that for other doctors it can all be a little more daunting.
“I am aware some doctors find using social media to be a baffling experience and they struggle to ‘get’ how it might be beneficial to them,” he said. “All my interactions online are with health professionals rather than patients so in some ways I escape some of the more difficult to navigate issues of social media.
“While some have clearly found it useful, I have no interest in using social media for medical politics. I can also see a health promotion role online.”
Dr Neill believes the challenges doctors have always faced in their relationships with patients are somewhat amplified online.
“The major issue is the personal/professional divide,” he said. “This issue exists in the real world, but is much easier to define there. A doctor knows when he is expected to behave like ‘the doctor’ and when he is OK to be a friend/father/spouse... Online these boundaries can be a bit more difficult as it is not always clear who is watching or who you are interacting with.
“Again, because I only tweet or write about the specifics of the technical aspects of practising medicine, most patients are not interested.”
So for Dr Neill the issues online are not fundamentally different than those faced by doctors offline.
“They are just a little bit trickier to identify or navigate in the online world where the rules are often not as clearly defined,” he said.
“I see a role for doctors representing themselves well online for patients to be witness to.
“We remain a respected profession and hold a privileged position and our behaviour online, as an enthusiastic, humble, caring and keen to learn physician, is important for society to see.”
We remain a respected profession and hold a privileged position and our behaviour online, as an enthusiastic, humble, caring and keen to learn physician, is important for society to see
On an international level, doctors have been very active in social media. In the most intense scenario, young doctors have used Twitter and Facebook to help ferment revolution during moments of high political drama like the Arab Spring.
Working tool
In the more prosaic professional arena, doctors in the United States have led the way in using social media as a working tool. One doctor who has been on board for some time is Dr Paul Sufka, a certified rheumatologist from Minnesota. Dr Sufka has an active blog and Twitter account. He is also a regular podcaster and was involved in starting up a rheumatology podcast (http://therheumatologypodcast.com/). He has a particular interest in the use of technology in medicine.
“I got started on social media probably just a little earlier than many of my peers because I have always been interested in technology and consider myself an early adopter of anything new,” he told MI. “As a younger physician, many of my peers are also on social media to some extent.”
Dr Sufka is glowing about his experience as a physician online, describing it as “nothing but positive”. He is also very enthusiastic about the international connections that social media has allowed him to develop with foreign doctors.
“I have contacts with other doctors all over the world. It has allowed me to keep up with medical information in ways that I never would have been able to by just subscribing to journals,” he said.
“Examples would be following people who are at medical meetings that I am unable to attend, and reaching out to interact with them to enhance learning.
“Social media also helps break down some of the information silos that are present in medicine. It is very easy for doctors of many different specialities to interact, and to get perspectives from across the globe.
“A few other things that have happened that I attribute directly to social media include being involved in starting up a rheumatology podcast which is a way that myself and two other rheumatologists have found to contribute to medical learning, and has been very well accepted.
“I have also been asked for advice on developing an iPhone app for rheumatoid arthritis, which I found very fun and exciting to the point I would like to be involved in these types of things in the future.”
In all this obvious enthusiasm for the world of social media, Dr Sufka is still keen to stress the particular concerns faced by doctors online.
“Beyond just privacy issues, which I think doctors are well aware of because of laws prohibiting breaches of confidentiality, doctors have to be very careful in what kind of advice they give to patients about questions that they get online,” he warns.
“If one of my own patients contacts me through social media, I bring the conversation back to a more appropriate channel of communication.”
Doctors, like every other sector of society, must deal with the rapid development of social media. But it seems that the most active online doctors have thought carefully about how they conduct themselves in this new arena. They know that any online professional slipup or ethical mistake will quickly have real world consequences. Yet most seem happy to focus on the positive opportunities that social media provides them both professionally and personally.
Watching your step on social media
The IMO and HSE have extensive guidelines as to how medical professionals should use social media. The HSE’s Social and Digital Policy is for all employees. It is quite detailed in its warnings of potential problems staff could encounter after a wayward tweet or an ill-advised Facebook update.
Of more interest to doctors is the recently published IMO Position Paper on Social Media. The detailed five-page document arose from a call from the membership at the 2012 AGM.
The IMO document gives the salient warning that it is often easy to misjudge when private becomes public online.
“It is often easy to forget or disassociate the online environment from being a public arena, particularly when it may just be you using your PC, smartphone or tablet,” says the IMO. “However, you should always be mindful that the content you generateon sites can reach a public domain regardless of your intention for the informationto be public or private.”
The IMO recommends not adding patients to your social network, accepting only people you know into your personal site, and avoid posting content regarding patients.
“Even if they, their care, symptoms etc have been anonymised, there is still the chance of identification,” warns the IMO.
“No content on social networking sites should ever reference patients or their specific case.”
The IMO, in general, says doctors should take a “conservative” approach to posting content on the internet.
“If you are unhappy with content that appears about yourself, take action to correct it.
“Routinely check your own internet presence to ensure that you are satisfied that the information about you is accurate and appropriate, particularly if that information is not posted directly by you.”
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