In 2004, Kevin Pho, MD, an internist in private practice in
Nashua, N.H., launched a blog to discuss breaking medical news. At first, his
expectations were low.
Fast forward to 2010. Pho’s blog,
KevinMD.com, now averages
310,000 page views per month. It has launched him to superstar status in the
realm of physician bloggers. His online presence has expanded to popular social
networking sites, including Facebook and Twitter. He is regularly sought out
for commentary in national media.
His blog is one example of the current power of social media.
“We needed a way for physicians to offer commentary quickly for
patients to know how medical news affects them,” Pho told HemOnc
Today. “Whenever a drug is recalled or there are changes in cancer
screening recommendations, for example, I can provide that context on my blog,
which can be dynamically updated at the speed of news break.”
Kevin Pho, MD, an internist in private
practice in Nashua, N.H., was an early adopter of social media.
Photo by Nashua Telegraph.
In November, the American Medical Association created a policy about
professionalism in the use of social media. Its guidelines include: maintaining
standards of confidentiality; using privacy settings to safeguard personal
information; and maintaining appropriate boundaries of the patient-physician
relationship. In addition, the guidelines suggest that physicians bring any
perceived unprofessional content on behalf of their colleagues to their
attention and, if the colleagues do not take action, to bring the matter to the
appropriate authorities. Lastly, the guidelines advise physicians that their
actions online may negatively affect their reputations and medical career.
From the Mayo Clinic creating a Center for Social Media to a 2009
Manhattan Research survey revealing that 35% of the US adult population uses
social media outlets for health and medical purposes, mounting evidence
suggests one certainty: Social media is here to stay.
One of the ways its presence is felt is that social media has made
health care more transparent, Pho said.
“By definition, social media encourages a two-way interaction, so
it gives patients a voice. Not only can patients look behind the curtain and
see what a physician thinks, but they can also respond to it,” he said.
“There is a lot more interaction, and that barrier between the patient and
health care provider has come down with social media.”
It used to be that the physician was the sole controller of health
information, but social media has changed this role, according to Bryan
Vartabedian, MD, a pediatrician at Texas Children’s Hospital. He runs
a blog called 33charts.com.
“The biggest thing that social media has done is to empower
patients,” Vartabedian said. “For the better part of modern
civilization, health information has been under tight control of physicians.
With the open access, patients now have unlimited access to information, which
puts them in a unique position. The role of the physician is being completely
redefined in the face of social media.”
A lot of inaccurate information exists on the Internet, and social media
is one way for physicians to provide reputable sources of information to their
patients, Pho said. Social media also provides an avenue for patients to give
feedback on the physician’s viewpoints.
“Having that guidance on the Internet is tremendously helpful for
both the physician and the patient,” Pho said. “If patients
don’t like what you have to say, they’re more inclined to say so via
social media. Seeing things from a patient’s perspective is definitely
illuminating, and it helps me become a better doctor.”
Rob Lamberts, MD, a primary care physician in Augusta, Ga.,
maintains the blog Musings of a Distractible Mind (distractible.org), through
which he talks about many issues, not just medical topics. He said his blog
provides a voice that he would otherwise not have in the professional world,
where many people, including other physicians such as those in academic
medicine, do not understand the issues unique to private practice, where
doctors see patients all day, every day. He said his blog has given him a
far-reaching platform for his opinions.
“The biggest change is that patients are communicating with people
other than their own doctors, including other patients with the same disease or
other doctors with various viewpoints. People get a truer perspective of
things,” Lamberts said. “The interaction through social media between
doctors, patients and nurses across the country and even the world has been a
very positive experience.”
Lamberts said he remains unsure of the overall effect social media will
have on health care.
“It’s like watching a movie. … You can’t take the
perspective of a single blogger,” he said. “You have to be willing to
look at it as part of a bigger picture. I don’t think people are doing
this as much as they should.”
Although using social media has many benefits, physicians must take many
things into account when maintaining an online presence. Remaining professional
is crucial to anyone who uses social media for work purposes. Even when using
social media as a personal network, rather than a professional tool, there
remain high standards of professionalism that everybody should adhere to,
In a 2009 study published in the Journal of the American Medical
Association, Chretien and colleagues conducted a survey of medical
school deans to investigate whether they believed their school’s medical
students posted unprofessional content online. Among the respondents, 60%
reported incidents in which medical students did post unprofessional content,
including profanity, frankly discriminatory language, depictions of
intoxication and sexually suggestive material. Just 38% of the responding
schools reported having a policy that covers the posting of such illicit
material by students. Among the schools that did not have policies in place,
only 11% reported that they were developing such a policy.
“People talk about carbon footprints and how everything you do has
an impact environmentally. We want people to think the same way about going
online,” Ryan Greysen, MD, MA, a Robert Wood Johnson Foundation
Clinical Scholar at Yale University and an author of the JAMA
paper, said in an interview. “People should be aware of their digital
footprints as well, and how everything they do online has an impact on their
professional lives. It also has an aggregate effect on the way the world views
In a paper in the Journal of General Internal Medicine,
Greysen and colleagues posit that social media is much like a mirror that
reflects both the negative and positive images of a user, and these images
“may prove very important in sizing up not only the credentials, but also
the character of professionals.”
The idea of online professionalism is that professionals, including
physicians, need to be aware of what they post online, and that their patients
and colleagues can view what they post as part of their professional persona,
Greysen said. Physicians should be aware that what they do on Facebook and
other social networking sites is part of their digital footprint and, thus,
part of their online professional persona.
Vartabedian said about once a month, a patient —either an
established patient or a new patient— attempts to reach him via his social
media presence for medical advice. However, interacting with patients in this
manner via social media is not advised.
“Physicians should not be having direct dialogue with patients in
public places, even if it is the patient who initiates the dialogue,”
Vartabedian said. “Anything that you would not do in public as a physician
is what you should not do on a social media platform.”
So how should physicians handle it when patients contact them via social
media? Vartabedian advised that physicians immediately take the dialogue
offline by prompting the patient to reach them via telephone. He also suggested
that physicians discuss with patients why it is not a good idea to have this
type of discussion in a public platform, as many people do not understand the
privacy issues surrounding the public forums in social media.
Vartabedian recalled a scenario in which a potential new patient
contacted him via Facebook and described a problem with her child. Upon reading
the symptoms she described, Vartabedian realized it was a very sick baby.
Rather than continue the discussion online, he had the mother call him at the
office. She did so, and they the baby received treatment.
“This represented a dilemma for me because I do not like to entice
these patient interactions in a public space, but here is a case where I did
not know what would happen to the baby if I didn’t answer that Facebook
message,” Vartabedian said. “As patients and doctors comingle, there
are going to be more and more subtle dilemmas like this.”
Pho also advised against giving personal medical advice out on the Web,
if not only for malpractice issues, but because you never really be sure of the
identity of the other person.
An especially important factor that physicians must consider when using
social media is privacy — specifically that of their patients. The Health
Insurance Portability and Accountability Act (HIPAA) of 1996 ensures patients
that their health information will remain confidential. But as careful as the
physicians may be in their social media realm, it is still possible for health
information to be divulged, unintentionally.
“Ironically, the whole issue of anonymous blogging is more
dangerous than blogging under your real name, as it makes it seem like you
would be freer to share private information,” Lamberts said. “The
blogs I’ve read that are the most audacious, and that make me cringe from
a privacy standpoint, are not those of the bloggers whose names are out there.
They are the bloggers who feel safe behind the guise of anonymity.”
Lamberts compared communication on Facebook and Twitter to elevator talk
and discussing patient information where other people can hear, and it may be
“We are taught through all of our training that we have to be
careful what we say, especially in public places,” Lamberts said.
“Twitter, for example, is a very dangerous place, and although you may not
mention a particular patient’s name, there’s always the chance for
Vartabedian said physicians may say things on a social media platform
that may be HIPAA compliant and not identify a patient by name. However,
physicians need to go above and beyond the HIPAA guidelines and probably avoid
the discussion of any patient-specific matters via social media.
“If I see a patient with a rare disorder, technically I could
discuss the case on Twitter without mentioning the patient’s name,”
Vartabedian said. “It may be HIPAA compliant, but ethically, if the mother
of my patient saw that I had written about it in a public platform, how would
she feel? I think it represents a serious breach in the relationship we
Physicians are encouraged to determine the goal of their social media
presence, whether it is promoting their practice, promoting themselves and
speakers, or advocating an issue they are passionate about, Vartabedian said.
Once that is figured out, the physician needs to define where they want to do
it, such as a blog, Facebook and/or Twitter.
“I frequently encourage doctors to make a decision about where they
want to live in the social media world,” Vartabedian said. “For me, I
live on my blog, which is the hub of my social media existence. Twitter and
Facebook are outposts for what I do on my blog. Budgeting the time spent
participating in the social media activities is also an important piece of
advice for doctors who want to get involved.”
Pho spends about 3 hours per day on his blog. He urged other physicians
to consider the positives of social media and to also become involved.
“The patient engagement and interaction is a great
experience,” Pho said. “There aren’t enough doctors online, and
we need more legitimate medical providers to be online to provide better health
information than what is already out there.”
Lamberts said he spends about 4 to 6 hours per week blogging.
“One of the great benefits of the medical blog world is the
collegiality among people all over the world,” Lamberts said “The
Internet is about the communication of ideas. If you know how to use it well,
you can certainly use it to your advantage.” – by Emily Shafer
Should medical institutions create their own social media
A physician point of view
Many physicians are reluctant to get involved with social media because
of potential ethical issues. I do believe there should be guidelines to help
physicians because this area of social networking for physicians is so new.
Currently, there are no specific guidelines regarding physician’s social
media use. While the American Medical Association recently released guidance on
this topic, it is rather broad.
From the educational standpoint, it is about raising awareness. Some
physicians may not be aware of the permanency of what is published on the
Internet, or how anonymity is not truly protective online. These topics should
be included in medical school curricula. Recently, we had a discussion at the
Association of American Medical Colleges, annual meeting to help create
consensus of what is professional online. We also recently conducted a focus
group of medical students at George Washington University to evaluate what they
thought was appropriate to post online and their thoughts about institutions
creating guidelines for social media use. The general theme was that it was up
for debate in terms of what was inappropriate to put online. Students stated
that they did not want formal guidelines and wanted to take responsibility for
their own actions as professionals. They were very sensitive to feeling
controlled by their institutions, but felt that advice and awareness were
helpful, and that including this topic in professionalism curricula was
From an institutional perspective, if physicians are posting on social
media and identifying themselves with a particular institution, a disclaimer
stating that they represent their own view, not the institution’s view,
would be prudent. There should also be reminders regarding patient privacy;
even posting anonymously about a patient encounter creates the potential to
violate HIPAA by disclosing details that enable the patient to be identified in
some way. When institutional guidelines are being created, all stakeholders
— physicians, patients, institutional representatives — need to be
included in deciding how to best use social media responsibly.
Katherine Chretien, MD, is an associate professor of medicine at
George Washington University.
A legal point of view
If an institution is planning to enter the realm of social media, it
makes sense to have guidelines. However, rules for governing social networking
are an evolving topic. Social media is all about transparency and disclosure.
It serves as a reminder to look at all of the rules that normally apply, and
apply them to social networking as well.
From the legal perspective, employment law and laws that apply to
communications and advertising. Everyone has to be careful of what is published
on the Internet, with no engagement in defamatory communication. Employers must
be aware of this if they plan to instruct employees about what they can and
cannot do while social networking. For example, are there rules around privacy?
Do employees have an expectation of privacy? There need to be rules for
personal communication made as an employee on behalf of the employer, as well
as the ability of the employer to monitor those types of communications. These
rules are typically laid out in employer policies and procedures. Employers
should also consider establishing disciplinary guidelines for instances in
which an employee makes disparaging remarks about the employer: Is that grounds
for disciplinary action? What kind of discipline?
In the advertising context, if an employee plans to post saying,
‘Come to our hospital/practice because we have the best…’ there
should be disclosures that the employee works for the hospital/practice so it
is not misleading advertising. Federal Trade Commission rules exist regarding
Nancy Gillette, JD, is general counsel for the Ohio State Medical
For more information:
- Chretien KC. JAMA. 2009;302:1309-1315.
- Greysen SR. J Gen Intern Med.