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Physician Use of Social Media

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Professional Standards and Guidelines Regarding Physician Use of Social Media

Preamble

Physicians must be aware that participation in social media is subject to regulatory purview. When engaging with social media, physicians must not do harm to the reputation of the profession and the public trust. Physicians should be aware that any e-communications could be easily shared via social media.

Definition

The term “social media” refers to web and mobile technologies and practices that people use to share content, opinions, insights, experiences and perspectives online. Social media platforms are constantly changing and include Facebook, Twitter, YouTube, LinkedIn, and blogging sites among others. It also includes discussion forums such as Quora and Reddit. Social media can be used for both personal and professional purposes. Social media functions on a two-way communication model with social media sites highly accessible, informal and public.

Professional Standards

  1. When engaging in social media, physicians must ensure all communications, activity and social media postings are professional, ethical and do not reflect poorly on the medical profession.
  2. Assume all social media settings to be in the public domain accessible to all, regardless of privacy settings. Once information is posted online, it is impossible to remove.
  3. Responsibilities to patients:
    When using social media, physicians must:
    1. Not communicate with individual patients about anything pertaining to their medical care. Do not doctor on social media;
    2. Ensure that patient confidentiality is maintained;
    3. Not post identifiable patient photographs, without appropriate consent;
    4. Exercise caution when posting personal information on social media platforms; and
    5. Maintain appropriate professional boundaries with patients.
  4. Responsibilities to the profession:
    When using social media, physicians must:
    1. Comply with all of their existing professional expectations, including those set out in relevant legislation and codes of ethics when engaging in the use of social media platforms and technologies;
    2. Ensure adherence to all College standards including the Professional Standards Regarding  Conflict of Interest, Professional Standards Regarding Advertising and Public Communications by Physicians and Professional Standards and Guidelines On Advocacy and Public Communications by Physicians;
    3. Adhere to any copyright, defamation and harassment laws and rules of engagement; and     
    4. Remember that social media platforms are constantly evolving and be proactive in considering how professional expectations apply in any given set of circumstances.

Guidelines

Should physicians require further guidance regarding their participation on social media, it is recommended they contact the Canadian Medical Protective Association.

  1. Physician-Patient Relationship

Physicians should exercise caution and sound judgment when connecting with patients or their family members on social media, either when initiating an invitation or responding to an invitation to connect.

Social media is designed to be informal; soliciting opinions and encouraging comments and content sharing. Within the casual culture of social media, boundary violations can occur easily. Physicians are responsible to maintain the appropriate boundaries of the physician-patient relationship.

Physicians should review the College’s Professional Standards and Guidelines Regarding Sexual Misconduct in the Physician-Patient Relationship.

  1. Professionalism

If physicians identify themselves as doctors on publicly accessible social media sites, they should also identify themselves by name. Any material posted by those who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.

  1. Confidentiality and Consent

When publishing content on social media, physicians should follow the rules for publishing patient information in journals, textbooks and educational presentations. The consent process required when publishing in a journal and presentation is also required for social media. Physicians should review the Canadian Medical Protective Association’s: Consent – A Guide for Canadian Physicians.

Physicians should never provide any information that could be used to identify a patient, even in a closed or private-online forum. Although individual pieces of information may not breach confidentiality on their own, the sum of published information online could be enough to identify a patient or someone close to them. Privacy settings can be compromised. Content posted on social media is traceable even if posted anonymously. Social media content can be shared and commented upon, as such this content lives forever online and is often distributed widely.

Social media platforms are available for physicians to share information and discuss medicine, as well as provide a means for peer-to-peer education and dialogue. Physicians should ensure these sites are password protected so that only registered users have access to the information. Assume all social media settings to be in the public domain accessible to all, regardless of privacy settings.

Examples of unprofessional or inappropriate use of social media from actual reported regulatory or legal cases are provided below:

An RN highly criticizes her grandfather’s medical and nursing care via Facebook and is found guilty of professional misconduct by her regulatory body. The nurse’s appeal was denied by the Court who found off-duty conduct is subject to discipline by the regulator. Nurses may exercise their right to freedom of expression but not in a way that would harm other registered nurses or the nursing profession. (Queen’s Bench for SK Cit. 2018 SKQ110) The Queen’s Bench decision was subsequently overturned by the SK Court of Appeal and the nurse’s professional misconduct finding by the regulator was set aside. The appeal court found that the regulator unjustly infringed the nurse’s right to freedom of expression as the disciplinary panel failed to take a contextual approach in assessing whether this conduct was unprofessional. The appeal court was careful to not take its reasoning too far. It appears that as long as a contextualized approach is taken by regulators in scrutinizing social media posts by practitioners, findings of professional misconduct would likely be upheld. Societal views about the use of social media may conflict with professionalism standards.

Strom v Saskatchewan Registered Nurses’ Association 2020 SKCA 112

A patient consents to a surgeon sharing images of her breast reduction surgery for teaching purposes. The patient is then shocked to see a Snapchat video of the surgeon displaying the excess tissue in what she considered a non-respectful manner. The patient clearly did not understand what she was consenting to when she gave the surgeon permission to use intra-operative photos of her body on his social media account. Some authors argue that the usual consent process does not address the new ethical challenges posed by social media. The authors state that some aspects of the consent process for use of patient images on social media platforms is insufficient to meet ethical and professional standards. Images that may be appropriate for a professional journal may not be appropriate to publish on Snapchat.

AMA Journal of Ethics, April 2018, Vol 20, Number 4 :328-335

A male psychiatrist is active on social media. He belonged to a number of Facebook groups. He met women through various groups and began private conversations. He informed them he was single. He identified himself as a physician and provided medical comments about women’s mental health. He began making lewd comments and sending nude photos; asking for the same from women. The women told him to stop. He continued. The women complained to the provincial medical regulator. The physician was found guilty of conduct unbecoming.

Ontario (College of Physicians and Surgeons of Ontario) v Wright, 2018 ONCPSD 19 2018

A Facebook page belonging to a family physician posts about debunked COVID-19 conspiracy theories and alternative treatments for the disease. The family physician was cautioned by the provincial regulatory body to stop encouraging people to disobey Chief Medical Officer of Health orders during the COVID pandemic. The physician had been posting COVID-19 related misinformation on his Facebook account and had been previously cautioned for the same issue. Several of the links on his account carry warnings that they contain false or partly false information.

The physician’s defense that he was simply trying to foster debate about COVID related issues was not accepted by the College. The College cautioned him to comply with the Canadian Medical Association Code of Ethics that deals with the medical profession’s responsibility to act in matters relating to public and population health and health education.

The College of Physicians and Surgeons of Newfoundland and Labrador March 2021

A pediatrics specialist in Ontario was given face-to-face cautions by the provincial medical regulatory body. The physician posted comments on her social media account with respect to the COVID epidemic. The complainant alleged that the physician was spreading false and misleading information regarding COVID-19 that goes directly against the advice and recommendations of local, provincial and federal medical/science and public health authorities. Such comments as “COVID-19 is not a serious health issue; a vaccine is unnecessary; masks and lockdown are not necessary.”

The physician respondent was issued three cautions by the provincial medical regulator for lack of professionalism and failure to exercise caution in her social media posts and tweets. It was deemed irresponsible for a member of the profession and presents a possible risk to public health. The physician claimed her tweets were taken out of context; however, the regulator noted tweets by their very nature have minimal context. Tweets are limited in character length and Twitter users can like, tweet or retweet without reviewing previous posts to determine context or the poster’s perspective.

The regulator did not accept the physician’s position that her tweets came from a personal Twitter account that has no affiliation with her practice. The respondents Twitter biography clearly identified her as a physician and a leader of a group of physicians. The respondent’s tweets are accessible to the public and the public are likely to give significant weight and authority to her tweets given her profession.

Summary of decision of the Inquires, Complaints and Reports Committee – Dr. K. Kaur Gill

College of Physicians and Surgeons of Ontario

A urologist was disciplined by the CPSBC in 2015 for unprofessional conduct for taking a photograph on his personal cell phone of an unconscious patient’s catheter site without the patient’s consent. The physician further violated patient privacy by forwarding the photograph in a text message, along with a joke, to a third party who was not involved in the patient’s care.

The physician was transferred from the Full-Specialty class of registration to the Conditional-Disciplined class, received a formal reprimand and paid a financial penalty. He was also suspended for six months and during that time had to participate in various professional programs.

https://cpsbc.ca/files/disciplinary-actions/2015-07-22-Kinahan.pdf

A family practitioner was disciplined by the CPSBC in 2017 for unprofessional conduct for failing to get proper informed consent prior to taking a digital electronic medical record photograph for clinical purposes during the course of an examination of an exposed patient. He also failed to maintain adequate records at the time of taking the photograph and subsequently enhanced his clinical records at the time of responding to the complaint.

The physician was transferred from the Full-General/Family class of registration to the Conditional-Disciplined class of registration, received a one-month suspension, a reprimand and financial penalty and was required to take medial education in the area of ethics and professionalism.

https://cpsbc.ca/files/disciplinary-actions/2017-07-25-Milne.pdf

A former Northwestern University student claims that after she was admitted to an Illinois hospital for extreme intoxication, an ER physician took photos of her and posted them to social media sites with commentary about her condition. The ER physician refused to delete the photographs when he was asked to do so by hospital security. The ER physician may have known the patient through a mutual friend and posted those images in their social sphere. The complaint alleges that the patient never agreed to be photographed and was not even in a condition to provide consent. Taking pictures of your intoxicated friend and posting them for the world to see is not appropriate when you are a physician in a position of responsibility. The physician was terminated for the Facebook post. A lawsuit is pending. The physician is alleging the incident deserved only a reprimand, not termination.

Where Social Media Went Wrong for Medical Professionals — The Digital Apothecary.html

https://www.thedigitalapothecary.com/musings/2014/8/10/where-social-media-went-w

An off-duty employee in Michigan photographs an attractive female patient in the Emergency Department and posts the image on Facebook with the caption, “I like what I like.” Physician and several colleagues implicated in the incident are now looking for other positions.

Where Social Media Went Wrong for Medical Professionals — The Digital Apothecary.html

Physician displays inappropriate and unprofessional pictures on Facebook (e.g., pictures of intoxicated physician grinning while holding bottles of alcohol at a party). He did not identify himself as a physician. He is not acting in a professional capacity. Is this conduct unbecoming? Recent case law found there must be a sufficient relationship between physician personal conduct and the medical profession to engage the regulator’s obligation to protect the public interest. Off-duty conduct requires a connection to the profession which is not the case in this example.

Recommended Reading

College of Physicians and Surgeons of Nova Scotia:

Canadian Medical Protective Association:

CMAJ:

PEDIAA:

Document History

First approved by the Council of the College of Physicians and Surgeons of Nova Scotia: October 12, 2018

Reviewed and updated: December 10, 2021

Approximate date of next review: 2024