Commentary: The Good, the Bad, and the Ugly of Social Media

The rise of online social networks (OSNs) from obscurity to ubiquity has been truly spectacular. With more than 750 million active users, Facebook is now the most popular site on the Internet.1 Recent medical literature has pointed out the hazards and professional pitfalls of one’s “digital footprint.”2 The resident portfolio entries by Dr. Ben-Yakov and Mr. Strausburg highlight the beneficial and negative potential that social networks hold for physicians and physicians-in-training.3,4 As far as I know, these two portfolio entries both represent firsts for medical social media reports. Dr. Ben-Yakov reports the first positive patient outcome in which an OSN was a critical tool. Mr. Strausburg’s portfolio entry is the first documented account in the literature of a medical student’s personal experience with the negative consequences of social media on his or her academic career. I suspect this is more a function of Mr. Strausburg’s admirable integrity and professional bravery than of the rarity of such situations in medical institutions around the country. The body of literature outlining the professional risks one takes with one’s online profile has become considerably prolific, to the point that anyone with a remote interest in social media and medicine can quote it: A 2009 study of medical school deans found that 60% reported incidents where students had posted unprofessional content online. Some of these postings included patient information, inappropriate language, depictions of intoxication, and sexually suggestive material.5 Another study found that most medical students’ Facebook accounts listed personally identifiable information, and only one-third had their security settings as “private.”6 More than 70% of employers currently search Facebook and other social media sites prior to hiring applicants.7 This includes physicians. As pointed out by Mr. Strausburg, OSNs have multiple features that make them more prone to lapses of professionalism than “real-life” situations. First, they are often more public than one would imagine. If one has 50 Facebook friends (the average user actually has 130 friends8), and each of these friends had 50 friends, then 2,500 “second-degree” friends would potentially have access to ones photos, birthdates, and religious and political views if the privacy setting is set to “default.” This “Kevin Bacon effect” means that statements and wall posts that one assumes are being broadcast to a small group of friends are potentially available for much of the Facebook world. Harmless posts and photos shared among friends can become much more serious when viewed by a residency director, patient, or potential employer. Second, much of the material posted on Facebook is potentially permanent. For example, a photo that is shared with others remains after one’s profile has been deleted unless those with whom it is shared delete it. Additionally, posts by others or pictures posted by others of you are only able to be deleted by the poster. This makes “scrubbing” of one’s online profile difficult, at best. Aside from issues of professionalism, several authors have pointed out the difficulties posed for physician and nurse users of OSNs and weblogs with regards to privacy and ethical behavior.9 These privacy issues can affect either the physician or the patient. One recent study demonstrated that almost one-third of practicing physicians had knowledge of a patient visiting their online profile.10 This same study noted that most physicians did not think that patient contact in social networks was ethically acceptable. Alternatively, from the standpoint of patient privacy, one need not use any HIPAA-designated personal identifying information (PII) to inadvertently reveal the identity of a patient. Recently, a medical student at our institution was reprimanded when he posted a seemingly harmless anecdote about an incident on the wards. While this post contained no PII, a nurse on the ward was able to identify the patient to which the student was referring using only contextual knowledge. She brought it to the attention of some of her administrators, and the student was reprimanded for an honor code violation. Dr. Ben-Yakov astutely points out the positive side of social media for patient care: a hero story of using Facebook to track down a family member of an altered patient in an emergency setting in which information was limited yet crucial. It is intuitive that such uses of social media to help generate a positive outcome for a patient in distress is not only acceptable but admirable; I agree fully with this. However, one could envision where such forays into OSNs may be detrimental to the physician–patient relationship, and we have yet to formally codify the rules of engagement for use of such information. For example, what if a physician finds pictures that imply alcohol consumption for a person awaiting a liver transplant? Or smoking a cigarette for someone awaiting a lung transplant? Generally this information would disqualify the patient from transplant until they can prove abstinence for a period of time. Does such use of freely available social media data help to foster the patient–doctor relationship or serve to undermine it? It seems reasonable that the standards of informed consent and the importance of privacy rules should govern the use of social media for medical data gathering. For example, I generally ask a patient if I can call his or her spouse to gather more information. While this is not a written informed consent process as with procedural consent, it is a binding consent process nonetheless that serves to protect issues of patient privacy and safety. Protecting privacy in such a fashion serves to bolster the patient–doctor relationship and engenders confidence so that information sharing, which is vital to the patient–doctor interaction, is done in an atmosphere of trust. I would argue that such a process be undertaken before a jaunt into the world of Facebook or MySpace for medical data. One could argue that publicly available information obtained from a Google search or from nonprotected OSN data is “fair game” for the physician to put to use in a professional patient–doctor relationship. However, I would liken such activities more to that of driving down a patient’s street to see what he or she is up to, rather than a simple Yellow Pages search of his or her name. Such activities, while not necessarily breaking any laws or formal rules, do approximate the lines of ethical boundaries in a professional relationship, which is why informed consent would be necessary for social media searches. Dr. Ben-Yakov’s use of Facebook to help the outcome of his altered patient obviously does not require informed consent, given the inability to obtain informed consent from a patient in such a state. This situation was one of an emergency nature in which consent for use of information was unobtainable. In such situations, physicians have license to bypass the usual informed consent procedures to provide needed care in an emergency setting. It would not be reasonable to require an altered patient to give permission for her caregivers to search for needed demographic information to help with her care. Online social networks have dramatically changed the way we obtain information from those we know, and as Dr. Ben-Yakov has pointed out, from those that we may not know. These resident portfolio entries demonstrate the positive and negative aspects of the OSN revolution and have lessons for all professional users of these technologies. Social media has great potential for negative professional consequences related to lapses of professionalism and the blurring of one’s professional and personal life. Additionally, social media is a new information tool available to caregivers; however, caution must be used to avoid alienating patients with unintentional boundary lapses. Informed consent for use of social media for medical data gathering can help to avoid such pitfalls.