PracticalDermatology

The age of social media has taken hold in our society. Sites like Facebook and Twitter are now ubiquitous. They have become permanent staples in the cultural vernacular, and dozens of other media sites that cater to a variety of interests—from restaurant reviews to picture-sharing—have attracted millions of users. In fact, it’s fair to say that over the past decade, these technologies have rapidly redefined how we communicate.

In the healthcare field, savvy medical institutions and practices have incorporated social media in innovative ways, enabling them to better connect with patients while also promoting their services and expertise. On the surface, being active on the social media front makes great sense for physicians. However, despite the positive buzz for (and widespread acceptance of) social media that has circulated through healthcare wires and magazines in recent years, the rapid evolution of communication technology in our field has set forth a new set of challenges and potential repercussions for physicians using these media. That’s because the open, “social” nature of social media is in many ways an inherent violation of one of the cornerstones of medical care: Patient privacy.

The reality is that social media is a prickly business for physicians, particularly for solo practitioners. While hospital- or academic-based physicians are given strict guidelines on how to use social media and are also backed up by teams of lawyers and IT professionals, the doctor in private practice is much more vulnerable to an array of pitfalls of social media use. That is why it is critical for all physicians to educate themselves on the potential dangers of social media and to exercise great caution when using these technologies.

Privacy, Inadvertent Disclosures, and Professionalism

Our healthcare system is ill-equipped and unable to adjust quickly to the rapid changes of the digital age. Physicians feel the pressure to “keep up” with the changing times, yet there is no current accepted mechanism for them to do so easily, thanks, in great part, to the Health Insurance Portability and Accountability Act (HIPAA). Most physicians recognize HIPAA in the office or clinic setting. But how does HIPAA apply in the electronic and online forums? Casual texting, sharing a photo, tweeting, etc., may violate HIPAA regulations.

Sharing and/or disclosing any patient information regarding a patient in an open forum can be illegal and unethical, and most physicians would probably avoid such disclosures. Nonetheless, inadvertent disclosures, albeit well-intentioned, are commonplace in social media forums with patients and other physicians. Such exchanges may be detrimental to the doctor/patient relationship, perhaps even affecting patient care. They may represent an invasion of privacy—a clear violation—and there may be true liability that can arise from the comments and shared information, perhaps even approaching libel and slander.

HIPAA must always be considered when using sites such as Facebook, but physicians can still have a Facebook account for personal use, which should be set for maximum security to protect any information shared with colleagues and friends. Yet, such shared information with colleagues must be within the legal realm of “need to know” for patient care. Simply sharing information with another physician without impact on patient care is questionable and probably inappropriate.

In the medical arena, even without patient identifiers (i.e. name, date of birth, etc.), any disclosure, regardless of intent, is subject to scrutiny, and the physician is responsible and liable for any information s/he transmitted. Once something is transmitted digitally, the imprint is permanent. As such, physicians would be prudent to refrain from interacting with patients on sites such as Facebook and Twitter. Any online contact regarding patient care can be problematic, subject to interpretations, intent, etc., all of which may impugn good judgment, ethics, integrity, and professionalism.

Most physicians know how to communicate with patients and colleagues, but we may be more prone to let our guard down on social media. The high level of informality that permeates social media can compromise the basics of professionalism that play such a major role in our medical daily interactions. Physicians must be attentive regarding all facets of patient care, including shared information on social media. Professionalism also affects the level between physicians and the public at large. Anything less than good behavior, good judgment, and solid ethics can stigmatize physicians and medical institutions.

Finally, while it may be very apparent to some, it bears mentioning that social media technology should not be used in the same way as—or as a replacement for—teledermatology. Despite gaining some ground globally, teledermatology is still in its infancy, and in order to properly and legally conduct this type of service one must follow strict privacy guidelines and show proper documentation. Social media technology does not easily allow one to overcome these hurdles, and at this point in time it would be unwise to use it for such a purpose.

Proceeding with Caution

If physicians use social media, they must separate professional use from personal use, also known as “dual citizenship.” Strict separation between private and professional use requires close scrutiny and high security settings for personal accounts, coupled with strict avoidance of any tangible discussion of professional matters, e.g., a mention of a bad day at work is much safer than mentioning how a patient made it a bad day.

Some physicians avoid social media for professional use, but many participate, at least to some degree, mainly for personal use or marketing/promotion. As social media represent the future, digital technology will continue to expand its role in medicine. As more people, especially younger generations, are “wired” to this technology, everyone engaged needs to avoid common pitfalls.

If physicians use social media for patient contact, the dialogue should be one-way. Information to educate the masses should not be predicated on responses and comments. Medical licenses are limited to particular states; engaging in a Q&A, even in general terms, could potentially constitute practicing medicine without a license. Offering medical advice to a patient could imply a contractual arrangement subject to liability, which may not be covered by medical malpractice. Such contact requires clarification with your insurance carrier. In addition, offering medical advice to a patient could be construed to establish a physician-patient relationship if it was reasonable for the patient to rely on the advice.

The use of Facebook or Twitter as marketing tools is subject to many ‘Dos and ‘Don’ts.’ For example, consider a scenario in which a practice has a “message of the day” regarding sunscreen. A patient calls and asks which sunscreen to use, which could set off a cascade regarding medical advice and a patient relationship, and possible liability. From a legal perspective, the scenario could create reasonable reliance and a possible physician-patient relationship.

Most information regarding sunscreens is already in the public domain (as with other general topics), so much leeway already exists. Nevertheless, a person may reply negatively regarding a particular recommended sunscreen. As such, keep any social networking contact (even promotional) one-way. Dr. Oz can appear on television and talk about a sunscreen product he liked, but his ‘information’ is one-way, directed at an audience. Again, information should be one-way.

Physicians need education regarding digital communication in the 21st century. Such education will hopefully be available via continuing medical education. Medical schools have already begun to offer courses on professionalism in the digital world, especially how to separate private use from professional use. But practicing physicians are forced to learn ‘on the go.’ Thus, it is important to learn as much as possible about the legal aspects and devise a well-structured plan for using social media.

While it is sensible to proceed with caution with anything related to patient care on social media, it is also important to remain open to the possibilities and potential that social media provide. For example, secure sites such as Sermo (www.sermo.com) and Doximity (www.doximity. com) allow physicians to share clinical photos and dialogue with colleagues. These sites are essentially medical social networks that allow clinicians to offer and receive comments regarding patient care and management with potentially less risk of liability.

Other forms of digital technology that resemble social networking may be helpful tools for patient contact. For example, a service called ZocDoc (www.zocdoc.com) is a secure, online appointment booker that interfaces with a scheduler and provides appointment slots for connected patients. Sites like ZocDoc provide patients freedom and flexibility to schedule appointments, and, in turn, builds goodwill with patients.

Do No Harm

Patients first. Protect the patient. Care for the patient. Do no harm. The doctor-patient relationship represents quite the opposite of what social media represents. The doctorpatient relationship is special and personal. To share most patient information outside of the context of that relationship is wrong, regardless of the media. Thus, in many respects, the issue of inquiry does not just concern social media, but rather how to amend the laws that govern medicine in a changing culture. Social media has simply become the symbol of the age and the vehicle for many of these changes

The bottom line for physicians in the digital age? Refrain from treating anybody online. Establish policies for ‘gray areas,’ if they occur, regarding social networks for educational or promotions purposes. Keep the communication one-way (i.e., no dialogue). And finally, consulting with colleagues who have successful social networking profiles may help to avoid missteps, embarrassment, and even legal problems.

For some perspective on how to situate social media as part of the trajectory of communication technology in medicine, it helps to recall the last “new wave,” about 10 years ago: the website. The intent was to enable patients to learn office hours, location, and credentials, as well as an introduction to physicians. Some physicians, excited by the possibilities, chose to dive right in to the business. Others to this day have resisted and still do not have a website for their practice. Years later, we have learned that a website only serves its true purpose if it is executed appropriately. In a way, the social media revolution should be viewed in a similar manner. The difference now is that social media can shift how we approach our professional responsibilities even if our clinical responsibilities remain unchanged. Given the importance of professional codes of conduct and how we interact with patients, clinicians are better off thinking about social media as a professional tool whose benefits can only be derived from careful consideration and measured application.

Today’s technology should help physicians to better connect with patients. That encompasses anything that makes a practice run more efficiently or that expands platforms for promotional or educational resources. While the inherent goal of social media is to facilitate “connection” among users, it is important for clinicians to understand that more connection does not necessarily mean better connection. That is why we must approach social media with caution and consider the perils as well as the benefits of the unprecedented level of connection that social media engender.

Mark Kaufmann, MD is an Associate Professor of Dermatology at the Mount Sinai School of Medicine in New York, where he also is in private practice.

Neal Bhatia, MD is an Associate Professor of Dermatology at Harbor UCLA and is also in private practice in Long Beach, CA.

Abel Torres, MD, JD is Professor, Chair, and Director of Mohs Surgery at Loma Linda School of Medicine in the Department of Dermatology in Loma Linda, CA.

Jeffrey Suchniak, MD is a dermatologist in private practice in Rocky Mount, NC.

Kenneth Tomecki, MD is Vice Chairman of the Department of Dermatology at Cleveland Clinic.