Humans are social animals who love to share their thoughts and feelings. For a long while, this sharing was done in small increments, either over the phone, in-person or maybe with a couple of e-mails. Then, along came social media and the slow drip of the faucet became the blast of the fire hose, allowing everyone to share everything with everybody all the time. Though this sharing can be positive and let people learn new things and feel more connected, it can also blur the lines between the public and the private, as well as the personal and the professional. Though it’s a good idea for an ophthalmologist to be up-to-speed and involved with social media, it’s easy to fall into some traps while doing so. Here, physicians with a special interest in social media issues share their advice on how to stay out of trouble on social networks.

Separate Your Media Lives

Rather than rushing into the social media maelstrom and being blindsided by a problem, experts say it’s good to step back and evaluate why you’re doing it.

Jeanne Farnan, MD, an associate professor of medicine at the University of Chicago Medical School, was the lead author on the American College of Physicians’ and the Federation of State Medical Boards’ position statement on online medical professionalism.1 “We encourage people to think about what their objectives are when getting involved with or having a presence in social media,” she says. “Many have a practice Facebook page and are interested in marketing, while others do it for advocacy. At a national meeting I attend, there will be a tremendous Twitter presence of folks sharing information, so some get involved in social media for educational or scholarly reasons. You should establish some principles ahead of time that will help you when sticky situations arise. For example, I have a LinkedIn profile but not a Facebook one, and I don’t have students who are enrolled at my institution as connections, because I’m in an evaluative capacity over them. When they graduate and become residents, however, I’m happy to have them as connections.”

Many surgeons, especially younger ones, want to be able to enjoy using social media, but also want to keep their relationship with patients on a professional level. To do this, physicians recommend having two profiles on sites like Facebook. “The main thing is to keep your public social media page professional; don’t let anything personal creep in,” advises Alex Cohen, MD, PhD, a corneal specialist in Iowa City who maintains an active social media presence. “This includes such obvious things as not including ridiculous pictures from the weekend but, on a subtler level, remembering that not every patient will agree with your political views or even your views on such things as hunting. If you want to have a personal page for use by friends and family where you can post such things, you might want to create it using an alias. For example, my younger brother has a page that uses a name that’s slightly different from his real name.”

One issue that arises is when patients want to “friend” you on your personal page. “You need to have a policy up front,” says Dr. Farnan. “Here, if a patient sends a friend request, we encourage residents and faculty to ignore the request and then have a conversation the next time the patient’s in the office. At that time, say, ‘I make it a policy not to share my personal information with patients in order to keep the relationship professional. If you prefer, we can use e-mail or a patient portal.’ Patients usually respond pretty well, and don’t push the issue.” She says having a Facebook page for your practice, as discussed by Dr. Cohen, is a good solution, since patients can friend that and just interact with the practice rather than your personal page. “Many physicians do this,” she says, “though there’s been a moderate amount of pushback against it from physicians, especially young physicians, who don’t want to have to update and monitor two profiles. But, it’s important to understand that it’s for both your protection and the patient’s.”

Online Communications

Once you’ve set up a page where you feel comfortable sharing public information, you also have to concern yourself about what information you and patients share, since health-care information is protected by laws such as the Health Insurance Portability and Accountability Act.

In the atmosphere of sharing on social media, patients will often post health-related questions in the public area of your Facebook page. Physicians say the proper way to deal with these questions depends on the patient and what he’s asking. “Communications with patients with whom you have an existing relationship, vs. people you don’t know, are different entities, as are general questions about diseases vs. specific questions about a patient’s own health,” says Dr. Farnan. “The instance of a patient reaching out with a general question about a disease, such as cataract, for example, is a key part of the argument why doctors need to be a part of the conversation on social media. Most adults and teens go online to search for health information. As physicians, we have a responsibility to point them toward resources that are vetted.

“However, if a patient asks via social media about his particular experience with a disease or asks for therapeutic recommendations, that’s a different story,” Dr. Farnan continues. “Providing answers to questions from patients you haven’t seen or examined in the office is a sticky situation. If it’s an existing patient of yours whom you’ve treated and for whom you can easily answer a question in a HIPAA-secure way, then I think the response is up to the physician. A phone call, for example, could handle such a situation and avoid dragging an existing patient into the office unnecessarily. But for someone who’s not your patient and who asks a specific question about her health, I think it’s better for the physician to say, ‘We don’t have a relationship yet, so we should do a formal evaluation in the office.’ This is because a ‘curbside consultation’ via a social network page could get a physician into trouble, since the patient might later say, ‘The doctor said X or Y to me,’ even though the physician never actually saw the patient.”

Ravi Goel, MD, a clinical instructor at Wills Eye Hospital who practices at Regional Eye Associates in Cherry Hill, N.J., says electronic medical records make it easier to deal quickly with social media diagnostic questions. “Now that we have moved to EMR, if a patient asks me a question by e-mail or Facebook, I generally call him back and document that I called him in the medical record,” he says.

Iowa City corneal specialist Alex Cohen makes sure his social media sites are useful by providing plenty of instructional videos on various types of procedures.
Another, more subtle, danger of the social media world is the risk patients will view anything you say as your professional opinion as a physician, rather than just one person’s opinion on the Internet. “When I speak to medical students, I remind them that there are only two professions in which you actually change your name: the clergy and medicine,” says Dr. Farnan. “I’m Dr. Farnan in the hospital and in my practice, but I’m also Dr. Farnan at the store and on the Internet. Representation is a huge issue. So, even though you may not be speaking as a physician when you tweet something like, ‘I support this candidate for president,’ it may be passively implied. It’s important to consider how your comment or message will be perceived by patients, students and colleagues. What will the message say about you, and you as a representative of the profession? Always pause before posting.”

Patient-targeted Googling

Today, physicians have unprecedented access to their patient’s personal lives and behaviors thanks to social media profiles. Experts continue to debate whether physicians should avail themselves of this information.

The ethical ambiguity of looking up a patient on Facebook, absent any codified guidelines, is illustrated by an example from an editorial in the Journal of General Internal Medicine.2 In it, a patient underwent genetic testing for breast cancer that found certain gene mutations, and resulted in the need to counsel her about mutations that could lead to cancers in the future. However, years later, the genetics lab sent an amended report: A gene variant turned out to confirm a diagnosis of Fanconi anemia, a rare bone marrow disorder. The variant also conferred a 100-percent chance—rather than the initially quoted 50-percent risk—of any offspring also having Fanconi anemia. The patient had been lost to follow-up, however, and the physicians saw Googling her as a requirement in order to notify her of the diagnosis.

Though at first blush ophthalmology might seem immune from behaviors that could be identified on Facebook, there have been cases of unhappy LASIK patients contemplating suicide, patients using unregulated colored contact lenses, at-risk AMD patients constantly smoking and patients fooling around with fireworks. Evidence of all of these behaviors could conceivably be found on a Facebook page. Dr. Farnan says that, in general, it’s probably best to avoid the temptation to check up on patients. “It’s a two-way street,” she says. “We expect patients to respect our private lives, so we should respect theirs. There are many caveats, obviously, such as a patient who’s a threat to harm himself or others, but again, you have to ask, ‘What’s my motivation for checking?’ In reality, most who publish in this area agree that it’s probably not a good idea. We need to focus on our connection with the patient in the office. In many cases, you can’t even determine the validity of what you find; you don’t know that the Facebook profile belongs to the person you think it does.”

Sharing Case Studies

One of the most useful aspects of social media is the ability to share your patient cases with colleagues (to demonstrate a new technique or request “crowdsourced” advice) or with patients (so they can see what a procedure actually looks like). However, as with other social media posts, you have to be aware of privacy issues.

Dr. Goel says he’s seen some questionable things while cruising through pages. “I attend AMA meetings, and I’ve become friends with young medical students and residents,” he says. “And I’ll often contact them to let them know there may be some serious HIPAA privacy issues with the cases they recently posted. We’re a profession that learns by sharing, so you want to be able to educate colleagues. However, you have to be mindful of patient privacy when discussing any type of clinical or surgical care online.”

Dr. Cohen says videos are a mainstay of his pages. “My Facebook and YouTube pages are teaching pages,” he says. “During my education, I learned a lot from social media, and that’s why my pages are dedicated to instruction. I’ve gotten comments from physicians that one of my YouTube videos helped them learn a procedure.”

Posting a surgical case requires that the patient be anonymous, which is relatively easy in ophthalmology since the view is often just of the eye. Sometimes, however, a patient presentation is so specific that extra measures are required. “If the circumstances of the case are unique, I’ll often change the patient’s gender, his age and sometimes even the circumstances,” Dr. Cohen says. “I may even wait a year after the procedure before posting it. However, despite this, if the case remains identifiable, I’ll secure the patient’s permission.”

Ultimately, similar to building an immunity to a virus, Dr. Farnan says frequent exposure to social media will actually teach you how to use it. “It can be tough telling the younger generation to curtail their social media habits,” Dr. Farnan says. “But, by the same token, they’re more savvy and aware of the pitfalls. And, of course, the people who don’t use social media at all can’t get into trouble. It’s the ones who use it sparingly who often don’t understand the full ramifications of what they post. It’s the kind of person who lurks on Twitter and then posts something terrible who has to be careful.”  REVIEW

1. Farnan JM, Sulmasy LS, Worster BK, Chaudhry HJ, et al. Online medical professionalism: Patient and public relationships: Policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 2013;158:8:620-627.
2. Baker MJ, George DR, Kauffman GL. Navigating the Google blind spot: An emerging need for professional guidelines to address patient-targeted googling. J Gen Intern Med 2014;30:1:6-7.