Professional Use of Social Media by Hepatology Providers
In 2018, we challenged the readers of HEPATOLOGY to lead the international conversation about hepatology on social media.(1) and you stepped up. The American Association for the Study of Liver Diseases (AASLD) has seen a near doubling of Facebook followers since 2017 (6,173 to 12,047) and an even greater increase in Twitter followers over the same period (7,649 to over 19,000). On Twitter, #LiverTwitter is increasingly used to centralize discussions of the hepatology community.(2) With increasing use of social media by the hepatology community and a global pandemic thwarting our ability to engage in meaningful in-person networking, the role of social media for AASLD members will only continue to grow. In this editorial, we will look at common challenges that arise on social media through the lens of the three pillars of AASLD’s code of conduct—professional, scientific, and personal integrity—and offer examples of how to manage them.
Professional Integrity
Scenario 1: You post a tweet recommending a medication regimen for prophylaxis of variceal hemorrhage, including “this is the [insert institution] way.” A patient at another center replies to your tweet by stating they are not on that regimen and asking if they should switch. You respond “yes.”
This scenario raises two concerns about professional integrity. First, unless you are an official spokesperson, avoid giving the impression that you are speaking on behalf of your university, hospital, or other affiliation (“this is the [insert institution] way”). Although your intention is to express enthusiasm for your institution’s work, your institution may object to you positioning your opinion as their official opinion. In addition to avoiding this impression in social media content, some health care providers include a statement like “views are my own and do not represent my employer” in their social media profiles. As you increasingly engage with social media, an early step should be to reach out to your department administrators and learn about institutional social media guidelines. Some employers recommend or require this disclaimer. We cannot cite specific examples of hepatology providers receiving disciplinary action for not using such a disclaimer, but reports of this nature are not publicly available. Although these disclaimers may protect your institution from legal action, they do not necessarily protect you from legal action from your institution or patients.
Second, it is important to avoid the impression (or reality) that you are providing medical advice through social media. In Scenario 1, the provider’s initial recommendation was directed at other providers, not at a specific patient. However, their response to the patient’s question could be considered medical advice. There are potential harmful consequences of diagnosing or providing clinical consultation through social media. First, providers may give incorrect advice without knowing the details of a patient’s case. Second, the provider may be publicly discussing the patient’s private health information, which is not best practice, even when the patient initiates the conversation. Third, engaging in medical care over social media can lead to oversimplification and misunderstanding. Finally, there are potential legal repercussions, as doctors have been sued for their medical advice, even when they had no direct contact with that person or reviewed their medical records.(3, 4)
One strategy for handling patient inquiries on social media is to encourage patients to speak directly with their provider. There are also physicians who walk the line of offering feedback to patient inquiries through social media without establishing a doctor-patient relationship.(5) If you choose to walk this line, we recommend being mindful of the potential harms, your institution guidelines, your comfort level with social media, and including a recommendation to speak with their provider.
Scenario 2: You find an excellent example of spider telangiectasia on a patient’s skin exam and ask their permission to take a photograph. You then post this on social media with educational facts.
Patients have a right to privacy. Central to patients’ trust in their doctors is the unspoken understanding that information shared with a doctor is privileged and will not be shared. Privacy is not only an ethical obligation of health care professionals but a legal one, too. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 provided national standards for the security of electronic health care information and privacy protections for individually identifiable health information. Although it is permissible to share anecdotes and nonidentifying aspects of the patient’s case, sharing identifiable information infringes on an individual’s rights.
Some violations of HIPAA are obvious; for example, a doctor who posted pictures of a young woman being treated for extreme intoxication to Facebook and Instagram.(6) However, there are some examples that are not as obvious, such as a nurse who posts a selfie with his favorite patient without consent.(7)
If you plan to share any information or imagery regarding a specific patient, you must completely deidentify it and obtain specific informed consent.(8) When deidentifying, answer the following questions: Could any detail be removed and my educational point still be made? Would the patient or their family member be able to identify them from what I’ve provided? Is there a tattoo or any other identifying material present? Is there any part of this description I can generalize?
Specific and detailed informed verbal consent is a minimum requirement of posting a patient’s case on social media. Consent must include specifics including the content of the post, the reason for wanting to share this information publicly, and which social media platform(s) are to be used. The relative permanence of online content should also be discussed during consent.(8) We recommend including a statement of patient consent in your social media posts about patient cases. Some have advocated to obtain this consent in writing.(9) Much like is done with published case reports, we recommend institutions create and distribute standard consent forms as well as approval and storage protocols for social media post consent.
Scientific Integrity
Scenario 3: Your laboratory generated exciting preliminary results that are planned to be validated in the coming weeks. After your laboratory meeting, you are so excited and post the results on social media.
Social media is publicly available and semipermanent. Consider social media posts as an extension of your laboratory or scientific platform. In that vein, we recommend only posting scientific content that you would otherwise publicize; this certainly includes peer-reviewed and published research. Articles published on preprint platforms can also be posted, as these are already widely available. With every post of scientific content, ensure the content is accurate, credit is appropriately given to authors, and conflicts of interest are disclosed.
Personal Integrity
Scenario 4: After a full day of endoscopy you take a selfie in an empty endoscopy room and post the photo on a public social media account with the caption “Longest Monday ever.”
A post like this highlights several issues of personal integrity on social media, the first of which is that physicians are held to a higher standard of behavior than our peers. Although this caption is benign on face value, imagine reading it as the patient who just underwent endoscopy. The patient might interpret the comment as a sign that the physician was fatigued and had not performed the exam to the highest standard. Although the physician could say to a coworker or friend “longest Monday ever” without personal judgment, this content on a professional social media page will be interpreted through a different lens.
Of course, providers are people too. It is normal at times to feel fatigued, frustrated with employers or colleagues, and annoyed about a specific type of consult. Commiserating over a shared negative experience can be a powerful tool to build community, and certainly, providers have enjoyed the comradery they have been able to build on Twitter. We do not suggest that providers cannot appear flawless or express any negative thoughts, but we do recommend as best practice a pause before posting to consider deeply the impact of your statement on other people, including patients, families, trainees, students, and colleagues.
Your employer may take action against you for posts like this, especially when they directly involve your job or photos taken on hospital grounds. You can be held responsible for social media activity even when the posts do not involve your job.(10) As Katie Duke, ACNP-BC, stated at the 2020 Association for Health Care Social Media meeting, “If you wouldn’t feel comfortable sharing it in an elevator, then don’t share it on social media.”(9)
Scenario 4 also raises the issue of the permanence and infinite audience reach of social media posts. Although the provider in this scenario may think they only have a few followers and those followers are their friends, public social media accounts are actually accessible by anyone. In addition, many posts are searchable and can be found years later. One solution is to have two separate accounts on a given platform. However, if your personal account can still be traced to you or your institution, all of the expectations of professional integrity stand.
Conclusion
Although we enjoy the benefits of social media, it is important to simultaneously uphold institutional guidelines, maintain patient privacy, avoid providing medical care through social media, and, most importantly, do no harm.
