Social media pose ethical unknowns for doctors

On a Sunday in late August, internist and pediatrician Rob Lamberts, MD, attended Journey Community Church in Evans, Ga., which touts itself as "the perfect church for imperfect people."

He posted the personal tidbit to his publicly available Twitter account using Foursquare, a location-based social networking website that lets smartphone users "check in" at various places to let the world know what they are up to.

"I don't mind that patients know where I go to church," said Dr. Lamberts, of Evans Medical Group, a five-physician primary care practice near Augusta, Ga.

He may be unusual among physicians in his online openness with patients about his personal activities. But as social media make it easier than ever for patients and physicians to connect outside the exam room, doctors face new questions about how to conduct themselves in these new spaces.

Facebook reported in July that it has more than 500 million users worldwide, and many physicians are among its users.

Nearly 1,300 physicians have registered on twitterdoctors.net, a listing of doctors using Twitter.

Some hospitals and medical schools have policies to direct physicians, medical students and other health professionals on how to use social media properly, but formal ethical guidance to help physicians maintain professional standards online is scarce. Doctors are largely on their own to devise rules on how to maintain appropriate boundaries with patients on social media.

The ethics of using social media were discussed at the American Medical Student Assn.'s annual convention in March, but the organization did not adopt policy. The American Medical Association Council on Ethical and Judicial Affairs will present a report on online professionalism at the House of Delegates' Interim Meeting in November.

The American College of Physicians' Center for Ethics and Professionalism is collaborating with the organization's Council of Associates, which represents more than 19,000 internal medicine residents and fellows, to formulate social media policy to include in a revised ethics manual.

"We have long accepted that there is a code of conduct that governs physician-patient interactions in a face-to-face setting, and online interactions are no different," said Erin Dunnigan, MD, chair of the Council of Associates and an endocrinology fellow at University of Texas Southwestern Medical School. "Physicians need to treat these communications with the same level of sensitivity and set boundaries where appropriate, so as to preserve the inherent trust of the doctor-patient relationship."

The Facebook quandary

Some doctors in training, at least, have been guilty of oversharing.

More than 60% of U.S. medical schools reported incidents of students posting unprofessional content such as photos showing inebriation or illegal drug use, or posts featuring vulgar language, according to a study in the Sept. 23/30, 2009, Journal of the American Medical Association. Experts said such online disclosures can undermine patients' trust, and a physician's obligation to never violate patients' privacy continues to be paramount online.

However, subtler dilemmas such as whether to accept patients' Facebook friend requests are more common, because physicians see an opportunity to use social media to advance their patients' health.

"A couple of generations ago, the house call was the common way physicians would find out about the real lives of people and make an impact right in the middle of their lives, and today it's social media," said Alan Greene, MD, clinical professor of pediatrics at Stanford University School of Medicine.

Dr. Greene accepts patients as friends at his personal Facebook page, but he refrains from posting anything too intimate. Most updates focus on pediatric health news.

Other physicians said they accept patients as friends on Facebook only if they have a previous personal relationship, not wanting to share private family news or similar matters. However, some doctors make exceptions.

Jennifer Shine Dyer, MD, MPH, a pediatric endocrinologist in Columbus, Ohio, has accepted four of her adolescent patients as Facebook friends because she found the service to be the best way to keep tabs on their progress and communicate with them between office visits.

"These are patients I've kind of worried about, and I know I'm a good influence on them," said Dr. Dyer, assistant professor of pediatrics in the division of endocrinology and metabolism at The Ohio State University College of Medicine. "They can know from reading my Facebook page that I'm going to be enjoying my life and maybe have a glass of wine or something, but I'm OK with doing that. I do think about it every time I post a status update."

Dr. Greene said doctors using social media need to remember that, whether they are in the hospital, the exam room or cyberspace, their behavior reflects on the entire profession. "Even though we are coming out from behind our stethoscopes and white coats in the social media world, that doesn't allow us to let go of our professionalism and ethics and responsibilities and our objectivity," he said. "We want to bring that into every patient encounter we have."