Think Before You Post: Navigating the Social Media Minefield – Healio

Social media users attempting to track COVID-19 via Facebook, Twitter, personal blogs or forums are likely to encounter as much misinformation as reliable information. The pandemic has thrown into sharp relief the importance of truth and facts in the online universe.

Social media has increasingly become a reality, if not a necessity, for rheumatologists hoping to advance their careers or exchange information. With so much at stake — either in a pandemic or in day-to-day networking and info-sharing — it is essential to be polished, professional and, above all, accurate.

If social media was once viewed as frivolous or the domain of bored teenagers and early adopters from Generation X, that is no longer true. Case in point: In their study in Rheumatology International, Negron and colleagues carried out an analysis of the hashtag #EULAR2018 to identify patterns of social media use pertaining to the Congress. In a study that included only tweets posted or shared during the 4-day stretch of June 13-16, 2018, they found 10,431 of them in that narrow window.

This raises the question, then, of what all these physicians, researchers, patients and other interested parties are saying about rheumatology.

“Social media use for physicians can be divided into two categories,” Suleman Bhana, MD, a rheumatologist at Crystal Run Healthcare in Middletown, New York, and chair of the ACR’s Communications and Marketing Committee, told Healio Rheumatology. “One is professional networking, and the second is for education.”

These are broad categories that might encompass a cross-section of professional activities. But all it takes is one poor choice — a photo of the swollen joint of a patient who did not authorize the post, perhaps — to put a physician at risk for privacy or Health Insurance Portability and Accountability Act (HIPAA) violations.

Further, doctors, of course, are people, too, and therefore are likely to have their own personal social media needs and goals. Patients and the institutions to which these doctors belong will see all of their profiles in totality. A clean work image could be undermined by questionable activity on personal accounts.

All of this raises the likelihood of wandering into gray areas rife with ethical conundrums. Clinicians must consider the dividing line between those personal and professional profiles. They must consider whether there are guidelines for social media use laid out by their institution or other organizations to which they belong. And they must consider the consequences of crossing ethical or appropriateness boundaries.

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It is perhaps for these reasons that there is still a significant proportion of the rheumatology community that actively avoids social media altogether.

Don S. Dizon, MD, professor of medicine at Brown University, offered another take. “One of the things that has, in my opinion, held folks back is the notion that social media has no benefits or is a waste of time, particularly for the busy clinician,” he said in an interview. “I would cast the benefits for rheumatologists as one of impact. We are living in an information age, but unfortunately, not all the information that people can now access is also reliable.”

It is with this in mind that Healio Rheumatology explores the ins and outs and dos and don’ts of social media for the busy rheumatologist.

Social Media Faux Pas

Jilaine M. Bolek-Berquist, MD, a rheumatologist with Mercy Health in Janesville, Wis., ran down a short list of those dos and don’ts in an interview with Healio Rheumatology. “Key dos include sharing only credible health information and resources, countering inaccuracies in the media, avoiding false medical claims and protecting the identity of patients,” she said.

While Dizon, of course, agreed on this last point, he acknowledged that there are ambiguities to consider. “Patient health information must always be protected, but that line can sometimes be very gray,” he said. “For example, you might have had an experience with someone with very severe lupus that impacted you in an emotional way, and you might have shared that on social media. Even if you do not name names, there is the possibility that that patient, or someone who knows her, might see it and identify herself as the patient you discussed without her permission.”

Bhana offered a similar example. “Seeing a patient with an unusual rash or presentation provides an opportunity for the clinician to educate the community,” he said. “I am often tempted to share pictures or information about a particularly unique patient so my colleagues can be aware of what to look for, but it is a good idea not to post about it in the afternoon after their visit. I often wait several months, at least, before sharing.”

A better idea might be to not post pictures of, or commentary about, troubling patients at all, or at least to ask permission before doing so.

Moving away from patient-centered issues, Bolek-Berquist offered a few more considerations for clinicians. “You should also disclose any compensation received, avoid anonymity, accurately state your credentials and always be clear about whether you are representing your employer or institution,” she said.

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Misleading claims tops the “don’t” list, according to Bolek-Berquist, along with misrepresenting board certification. “You also want to avoid posting pictures of intoxication or sexually explicit material and, of course anything illegal, which includes HIPAA violations,” she said.

For the most part, clinicians should intuitively be able to follow most of these recommendations, at least for their professional social media accounts. But one issue that compounds the ambiguity is that many doctors also maintain personal social media profiles.

Keeping Profiles Separate

Regardless of whether a clinician wishes to use social media for career advancement or information sharing — and the two approaches are not mutually exclusive — a good first step is to separate those personal and professional profiles.

For Dizon, it is best to accept the reality that most physicians desire to have personal social media accounts and are likely to blur some of these lines. It is for this reason that he noted the concept of “dual passports” as espoused by Mostaghimi and Crotty in Annals of Internal Medicine. In short, they recommend keeping the professional and the personal completely independent.

“One key consideration in this regard pertains to whether one should be following, friending or ‘liking’ posts by patients,” Bhana said. “Having a personal relationship with a patient outside of the office, even if it is a virtual relationship, presents too many potential compromises of professional objectivity.”

Even networking with colleagues should give clinicians pause, according to Bolek-Berquist. “In terms of social networking with other health care workers, the thought is to only network with colleagues you are not directly evaluating at the time,” she said. “For example, you would not want to ‘friend’ a current medical student, but once they move on to another rotation or to residency where you are not responsible for their advancement, it would be ok.”

While he agreed that caution is best, Dizon suggested that there is an argument to be made for blending the professional and the personal. “More and more, I am mixing them up a bit,” he said.

However, these lapses in professionalism can represent serious potential problems in most social media outlets. In their 2014 study in Physical Therapy, Gagnon and Sabus noted that several prior studies have reported high rates of unprofessional tweeting from accounts clearly identified as physicians. According to the researchers, ‘unprofessional behavior’ included profanity, complaints about patients, violations of patient privacy as well as conflicts of interest.

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Although many physicians strive to maintain separate professional and personal identities on social media, others are not so consistent, and therefore can find themselves susceptible to the same whims and miscues as the general public. “My advice to my colleagues is this,” Dizon said. “Do not tweet or post when, one, exhausted, two, angry or annoyed or, three, inebriated.”

If this advice is not enough, the Association for Healthcare Social Media, a 501(c)(3) nonprofit organization, was created to support health care providers on social media. The organization provides resources to help physicians who use social media understand HIPAA concerns, how to disclose conflicts of interest, industry relationships, and how to cite medical literature so patients and the general public can easily digest it.

Physicians who use social media regularly, or those who are just getting started, all can benefit from this information, because if the COVID-19 pandemic has emphasized anything, it is that the social media landscape can change on a daily, sometimes hourly, basis. Moreover, false or misleading statements can have fatal consequences.

Ethical Considerations

While the average social media post does not generally carry life-or-death ramifications, the division between that which is in poor taste and that which is truly unethical should be considered. “The biggest ethical consideration would be to disclose any potential conflicts of interest,” Paul Sufka, MD, rheumatologist and department chair at HealthPartners Medical Group and Regions Hospital in St. Paul, Minn., said in an interview.

To clear up uncertainties, the AMA has put forth a code of medical ethics relating to professionalism in social media use. The association encourages physicians to:

• Be cognizant of standards of patient privacy and confidentiality, and refrain from posting identifiable patient information online.
• Follow ethics guidance regarding confidentiality, privacy and informed consent.
• Use privacy settings to safeguard personal information when using the internet for social networking, keeping in mind that privacy settings are not absolute.
• Maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethics guidance.
• Consider separating personal and professional content.
• Bring unprofessional content posted by colleagues to their attention, or report the matter to appropriate authorities.
• Recognize that actions online may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers, and can undermine public trust in the medical profession.

Despite these clear guidelines, what happens when a physician crosses a line can vary from state to state or institution to institution.

“Currently online it is a bit of the Wild West with regard to policing inappropriate behavior, as everyone has different ideas of what, exactly, constitutes inappropriate behavior,” Bolek-Berquist said. “We have a responsibility to redirect our colleagues online if we feel they are violating professional standards.”

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Redirecting colleagues is one thing. Serious disciplinary action is another. Rheumatologists need to know what might happen when they cross those lines.

In their review in JAMA, Greyson and colleagues surveyed the 68 executive directors of all U.S. medical and osteopathic boards regarding violations of online professionalism and the actions taken. Inappropriate patient communication online — specifically, sexual misconduct — was reported by 69% of respondents. Inappropriate prescribing and misrepresentation of credentials were also reported by 60% or more respondents.

As for the disciplinary actions taken, formal proceedings were held in 71% of cases, hearings were held in half of cases, physicians agreed to sanctions without a hearing in 40%. The overall rate of serious disciplinary consequences, such as license restriction, suspension or revocation, occurred at 56% of the boards.

“Some folks have been sanctioned by their institutions for their social media activities, others by state boards,” Dizon said. “The sanctions can range from fines if there is a break in HIPAA rules, to loss of employment, to surrendering of their own social media accounts and outright censorship.”

One way to mitigate these outcomes is to be clear about who is saying what, according to Dizon. “If you are a part of an institution, making it clear that you only speak for yourself, if that is indeed the case, is important,” he said. “But it is also important to be deliberate with social media activities. We are professionals after all, and at the end of day, you need to stand by the activities you pursue and partake in.”

Educational Tool

Experts have noted that not all social media activities necessarily have to be ethical minefields. Social networking platforms enable physicians to share information with a broad audience, from other physicians to trainees to patients, with other users determining what content should be viewed as useful and accurate through ensuing discussion and reactions.

Social media can also serve as an important vetting area for newly published research, inviting critical commentary and opinions from the wider physician community in a more relaxed forum than crafting commentaries for official publication in a journal.

Although blogs, wikis and media-sharing sites all contribute to the larger physician sphere of social interaction, the reality is that many social media users check in to one or two sites through the day to see what is happening. Of all the social media platforms, Twitter appears most popular among medical professionals — perhaps due to its rather succinct features. Physicians can respond directly to information shared through Twitter with quick criticism or endorse them with “favorites” or “retweets” that often, in turn, validates that information for other physicians. The use of “hashtags” in Twitter also allows users to focus their discussions, broadcast trending topics to even wider audience and invite additional questions and comments.

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In a field as fast paced as medicine, in which professionals often lack the free time to consume information, the brief information bytes and rapid response critiques offered through Twitter often enable even the most overwhelmed physician to stay ‘in the know’.

In their study in the European Journal of Hospital Pharmacy, Martinez-Lopez De Castro and colleagues analyzed the volume and content of tweets pertaining to biological therapies for chronic inflammatory arthropathies. A number of keywords underwent analysis, resulting in 2,480 tweets that ultimately were included.

Among 983 tweets pertaining to therapies, adalimumab (Humira, AbbVie), infliximab (Remicade, Janssen) and etanercept (Enbrel, Amgen) were most common. Rheumatoid arthritis was the most commonly tweeted disease, followed by psoriatic arthritis and ankylosing spondylitis. Other highlights included tweets about safety or adverse events, drug infusion and self-administration.

“Learning more about the patients dealt with in the tweets will enable us to improve our understanding of the areas of greater interest and concern among patients,” the researchers wrote. “This could help hospital pharmacists establish patient-focused strategies addressing the needs of the patients.”

Where all of this information is concerned, Dizon underscored the importance of reliability. “This is where we as health care professionals can make the most difference,” he said. “We can point toward good resources and point away from misinformation.”

This may be an increasingly difficult task for physicians as Twitter offers no official process to check for misinformation, instead relying on crowdsourcing from its users to vet statements for accuracy.

In particular, celebrities on Twitter often present a significant hurdle in proliferating misinformation. Often given “verified account” status – Twitter algorithms prioritize celebrity accounts as being of higher “public interest” – celebrities with no formal expertise on health care topics regularly voice their opinions on them, and are often presented as credible sources to Twitter users. This can present a particular problem for patients using Twitter as a resource to make informed decisions regarding their care.

Connecting to the Future

Regardless of how it is used, one thing is certain: Social media is not going anywhere. The more a clinician or researcher can learn about what is happening in the online universe, the better positioned they may be for success.

Further data from Negron and colleagues showed that the key topic associated with the #EULAR2018 hashtag was “patients,” while sharing knowledge from the meeting, marketing or advertising and sharing experiences or thoughts were the primary themes. The researchers suggested that there was a “staggering” amount of information coming from the meeting and urged leadership to “recognize the value and power” of this information to shape the organization in the future.

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What social media has demonstrated is that these organizations, after all, are made up of the individuals who belong to them and participate in the events. Part of that “value and power,” then, is not just the information itself, but how social media users respond to that information and connect with each other about it.

“The best way to get into using social media as a physician is to be active on it during one of the larger rheumatology meetings, even if you cannot be physically present at the event,” Sufka said. “This is a time to identify colleagues with similar interests and make connections. Do not be afraid to join a conversation.”

For Bhana, it can run even deeper than just connections. “Of course, social media has allowed me to meet people I never would have met organically at ACR or EULAR,” he said. “But curating content and observing and engaging other people’s content has opened so many doors for me and allowed me to have a leadership presence in ACR. I never would have gotten there without social media.”

More and more rheumatologists are following Bhana’s lead. Nikiphorou and colleagues examined social media use among 233 young rheumatologists and basic scientists from 47 countries in their study in Annals of Rheumatic Diseases. Regarding professional activities, about half noted that they used social media for clinical and research-related reasons. Moreover, 81% used social media to gather information, 76% for professional networking, 59% for new resources and 47% for learning new skills.

“Social media will continue to be a part of the life of physicians both at work and at home,” Bolek-Berquist said. “It allows us to collaborate with people all over the world, and to share information that has the power to result in better patient care.”

She noted, “Younger physicians have been raised with social media their whole lives and likely will strive to incorporate its use into everyday practice. For example, during the current COVID-19 outbreak, the international rheumatology community was able to quickly assemble to develop a registry of rheumatology patients afflicted with the disease. Without years of previous networking online, this would not have been such a smooth and effective project.”

As for the ethical boundaries discussed previously, Bolek-Berquist suggested that the social media landscape is constantly shifting. “It is not clear as to whether physician-patient social media networking will evolve in the future as a part of medical care, such as in online support groups,” she said.

Regardless, the opportunities to communicate are nearly boundless, and focusing on these positives could usher in a new generation of learning and connecting, according to Sufka. “I have always been impressed when social media helps break down silos between different specialties in medicine,” he said. “I am seeing a lot of this in the wake of COVID-19. People are becoming more and more willing to try to help their new online friends.” – by Rob Volansky

• References:
• AMA. Professionalism in the use of social media: Code of ethics opinions 2.3.2. Available at: www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media. Accessed Sept. 20, 2019.
• Gagnon K, Sabus C. Phys Ther. 2015;doi:10.2522/ptj.20130227.
• Greyson SR, et al. JAMA. 2012;307(11):1141-1142. doi:10.1001/jama.2012.330.
• Martinez-Lopez De Castron N, et al. Eur J Hosp Pharm. 2019;doi:10.1136/ejhpharm-2017-001402.
• Mostaghimi A, Crotty HB. Ann Intern Med. 2011;doi: 10.7326/0003-4819-154-8-201104190-00008.
• Negron JB. Rheumatol Int. 2019;doi:10.1007/s00296-019-04249-0.
• Nikiphorou E, et al. Ann Rheum Dis. 2017;doi:10.1136/annrheumdis-2016-209718.

• For more information:
• Suleman Bhana, MD, can be reached at 95 Crystal Run Rd. #403a, Middletown, NY 10941; email: suleman.bhana@gmail.com.
• Jilaine M. Bolek-Berquist, MD, can be reached at 3524 E. Milwaukee St. Janesville, WI 53546; email: jbolek-berquist@mhemail.org.
• Don S. Dizon, MD, can be reached at Lifespan Cancer Institute, Rhode Island Hospital, 593 Eddy St., George 302, Providence, RI 02903; email: don_dizon@brown.edu.
• Paul Sufka, MD, can be reached at 401 Phalen Blvd., St Paul, MN 55130; email: psufka@gmail.com.

Disclosures: Bhana, Bolek-Berquist and Dizon report no relevant financial disclosures. Sufka reports being the social media editor for @ACR_Journals (Arthritis & Rheumatology, Arthritis Care & Research, and ACR Open Rheumatology).