Social Media: A Necessary Evil?

We commend the authors of “The Plastic Surgery Social Media Influencer: Ethical Considerations and a Literature Review” in this issue of the Journal for advancing the conversation about the ethical issues of social media use by plastic surgeons.1 They approached the topic with a comprehensive literature review of publications linking ethics and sponsorship. Utilizing the four ethical pillars of medicine to structure the article is a novel way to organize their findings and concerns. Although they attempt to maintain a neutral position on social media and plastic surgery, the article touches on many topics that should be of great concern to our profession. Touching on the topics is not enough, however, because we need to explore them further. It is time for plastic surgeons to reflect and decide whether this is the trajectory we want for our profession. The article highlights the importance of confidentiality and informed consent with respect to patient autonomy. An important aspect of most “digital” consents is that patients have a right to remove their consent if they choose at a later date. However, the Internet and social media effectively nullifies this right. The article accurately points out that the Internet is forever. There are no “mulligans.” There are no “do-overs.” Should the age range of patients whom plastic surgeons want to utilize on social media be considered? A large portion of them are younger patients. Given that the prefrontal cortex, which is largely responsible for impulse control, is not fully developed until the age of 25,2 is it ethical to allow younger patients to make life-lasting decisions under the guise of education? We completely agree with the notion that the number of social media followers and the results of search-ranking algorithms can be very misleading to patients. The number of followers one has does not equate to that person’s experience, skill, or a dedication to education. The simple fact that you can purchase followers exposes the ridiculous nature of the metric utilized to guide ranking, trending, and potentially patient decisions. Is that justice? Beneficence is another idea that is interesting to dissect when it comes to social media. In what way does the patient benefit from being utilized on social media? Surgeons promote their work, they gain followers, their practices potentially become busier, they do more cases, and they make more money. It is hard to figure out how this is in the patient’s best interest? Nonmaleficence seems more closely tied with social media use. The posts are forever. No one can predict what is going to go viral. Can the agreement between the patient and plastic surgeon, under the cloak of education, unknowingly have an adverse effect on the patient and physician should the post go viral for any reason? Patients are at much greater risk of being harmed by social media than the chance of benefiting from it. Do we adequately inform our patients about the risks and benefits of social media before we post? The authors bring up many salient points in their discussion. The public needs to know when a professional is being paid or sponsored. It should be transparent and obvious. The public should not have to look for it, it should smack them in the face. We agree that the doctor-patient relationship is being compromised. Historically, physicians (including plastic surgeons) placed their patients first, with everything else being a distant second. As the likes and followers pile up, priorities are shifting, unfortunately. It does not take much time glancing through social media to quickly realize the plastic surgeon has become number one, the followers are second, and the patient is third. Some of our colleagues are more concerned about the creation of the “script” for the daily “film” in which they will star on social media than the patient care at hand. In fact, we believe that these individuals are becoming entertainers. They are possessed by these posts, further alienating themselves from their patients. In our minds, the most egregious posts are those from the operating room, while their patients are asleep. Is this truly in that patient’s best interest? Do the patients really understand what is in their best interest when they allow this? Are these physicians giving their patients 100% of their attention? One of the most interesting points in the article is broached in the Limitations section, although we disagree with the notion that it is truly a limitation. Social media has been linked to depression and conjectured to be linked with a rise in suicide.3 Plastic surgeons are among the highest represented medical users of social media. Will the pressure to be active on social media lead to higher burnout rates in plastic surgery? On November 8, 2019, Instagram CEO Adam Mosseri announced that Instagram is testing hiding “likes” in the United States, just as it has done in many countries around the world.4 Facebook, Twitter, and YouTube have all recently experimented with removing “engagement metrics” from their platforms. As reported by Wired, “Social media researchers have argued that when users tailor their content to whatever garners the most engagement, the result is a radicalized environment that makes healthy, happy conversations almost impossible.” 5 This new approach is designed to decrease the pressure that social media users feel from each post and to focus on the content promoting a “healthy user environment.” As stated above, this would eliminate the confusion that patients have regarding “followers” and their potential surgeon’s experience and expertise. If Instagram sees the potential problems, why can’t we? There are some things in the article with which we disagree. The first line of the article states, “Social media continues to be a platform in which medical professionals and residents can promote their work and educate their followers.” Although this is factually true, we need to look closely at the concept of residents promoting their work. We feel this is appropriate when residents promote scholarly activity such as publications and presentations; however, when residents promote their surgical results, this is not only misleading but also erroneous. By definition, a patient is never truly a resident’s patient. In the end, it is the attending’s patient, regardless of how involved the resident is. Unless this is explicitly stated on social media, these types of posts are misleading and dishonest. The article also compares plastic surgeons to academic surgeons several times. The idea that these two things are mutually exclusive shows how far we have strayed from our initial goals as a profession. A more appropriate distinction would be between private practice plastic surgeons and academic plastic surgeons. A common argument for the “all in” attitude toward the use of social media is “Well, people thought websites were unethical when they first came out. Now they are standard.” Although this is true, there are many stark differences between websites and social media. First and foremost, when a patient goes to a physician’s website, they have an understanding that a professional format is being utilized to promote the work of the physician. However, when a patient follows a surgeon’s posts, that clear distinction of promotion becomes muddied. “Educational” posts are more “promotional and entertaining.” It is analogous to the difference between PBS and Don King. One educates, the other sensationalizes and entertains. We have to decide as a profession if we want to be the Don King of medicine. Websites are professional. Social media accounts are just as the name suggests, social. Our patients are more likely to feel like a friend or like they actually know us. The professional lines can quickly become blurred. Many will argue that social media is a great way to build a practice and career. It has been shown that social media offers a superior return on investment than traditional marketing platforms.6 However, we have seen in many professions (politicians, athletes, and prominent plastic surgeons) that social media is also a quick way to end your career.7 When looking through the retrospectoscope, the common declaration from those who have seen their life’s work destroyed by social media is: “If I could go back and never be on social media, I would.” Although this seems obvious, no one ever thinks it will happen to them. But in the age of outrage, all it takes is one click of the mouse to erase the decades of hard work we have all put into our training and patients. One might read this editorial and think, “Those guys just aren’t with the times.” Maybe you are right. Maybe things are changing and we need to get on board or get out of the way.8 Maybe our views are skewed because we are two plastic surgeons who both work in academic settings.9 We are both dedicated to our patients first and resident education second. The senior author (J.M.K.) has been a practicing plastic surgeon for 23 years. He had a strong social media presence but started to realize the negative impact it had on his life, professionally and personally. He has watched his peers and former residents become caricatures of themselves. He still posts two or three times a month, because he was told he had to maintain a social media presence by his website marketing company. He understands that the posts are about him or he ensures the posts provide education without sensationalizing procedures. He does not post graphic patient before-and-after results, or worse yet, any operating room video. The junior author (S.D.) recently finished residency and has been practicing for less than 6 months. He has never had a strong professional social media presence. Coming from general surgery, he was immediately appalled by the behavior of plastic surgeons online. He has watched some of his co-residents become more concerned with the perfect post than living in the moment. He has seen residents on social media during rounds, conferences, meetings, and in the operating room. He personally spent hundreds of hours mindlessly scrolling through social media, until his son was born and he realized just how much precious time he was wasting. Social media followers and likes are not real. The people around you are real. The “you like me, I like you, we like everyone” phony nature of social media drove him away. A “like” will never replace a conversation. A new follower will never replace a new friend. Despite the obvious generation gap between us, we both feel that social media is a distraction from our profession and in many ways from the “oath” we took. The public can no longer decipher what a plastic surgeon really is. “Board-certified” has been replaced by “influencer” or “public figure.” Educator replaced by entertainer. Professional replaced by promoter. As more and more is revealed about the negative influence that social media exerts on our society as a whole, we need to take a stand as a profession. Plastic surgeons pride themselves on being at the forefront of innovation and change. Is it time to change? It is often said that social media is a “necessary evil.” One of those words is true. It is our job to decide which it is. Dr Kenkel is an educational consultant for Galderma and the recipient of research grants from Venus Medical and Bellus Medical. Dr Devitt declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article.