key: cord-331766-sdbagsud
authors: Kung, Janet WC.; Wigmore, Stephen J.
title: How surgeons should behave on social media
date: 2020-08-30
journal: Surgery (Oxf)
DOI: 10.1016/j.mpsur.2020.07.014
sha: 
doc_id: 331766
cord_uid: sdbagsud

This article documents the rise in popularity of social media use by surgeons for personal and professional use. It considers some of the important issues around privacy, patient confidentiality and professionalism and discusses some of the common pitfalls of using social media as a surgeon.

Social media has fundamentally changed the way we interact with the world and it has become an integral part of many surgeons' personal and professional lives. The most popular platforms include Twitter, Facebook, WhatsApp, Instagram and YouTube, and professional networking sites such as LinkedIn and ResearchGate have gained prominence in the healthcare sector. With their many facilities and applications, social media platforms offer opportunities for patient resources and education, professional networking, research collaboration and dissemination, public engagement and policy discussions, and personal and professional support. 1 A PubMed search for "social media" AND "surgery" has generated over 1820 articles to date, of which 118 articles were published in the first quarter of 2020, equating to an average of almost 40 publications per month in 2020 thus far. The volume of internet traffic during the COVID-19 pandemic has affirmed the role of social media in contemporary communication. As social media has become ubiquitous, it is critically important for surgeons, whether active enthusiastic users or passive apprehensive observers, to be aware of the potential risks and pitfalls and to take caution and control over their online presence. Inappropriate and unprofessional behaviour is susceptible to serious legal ramifications, which may lead to prosecution, professional censure, and loss of certification or licensure. 2 Many regulatory bodies and professional organizations across the world have issued guidelines and recommendations specifically to address the use of social media. For example, the General Medical Council (GMC) 3 and the Royal College of Surgeons of England (RCS) 4 in the United Kingdom, as well as the American Medical Association (AMA) 5 and the American College of Surgeons (ACS) 6 in the United States, have all provided relevant guidance. In general, applying common sense and adhering to traditional professional standards while online are advised for surgeons who engage in social media.

One of the most powerful aspects of social media is the ability to connect instantly to our patients. This very attribute of social media has blurred the boundaries between personal and professional life. Accepting a patient's 'friend' request on Facebook, and other direct relationships on social media platforms, is strongly discouraged as this may allow bidirectional access to personal information and commentary that is not traditionally appropriate for the surgeon-patient relationship. In the same way that you might not desire your patients to have access to the intimate details of your personal life, 'patient-targeted Googling' may yield information about your patient's healthcare and behaviour (e.g. smoking or alcohol consumption) that could colour your judgement and affect your interaction with them and their treatment plans. Not only is there the sensitive issue of disclosure of the source of information, there is the serious risk of spiralling into curiosity, voyeurism and invasion of privacy which could destroy the trust of the surgeon-patient relationship and reflect badly on the institution and even the entire profession. 6 To maintain professional boundaries, surgeons should consider separating personal and professional profiles online and comport themselves professionally in both. 3, 5, 7 If a patient were to contact you about their care or ask you to provide medical advice to acquaintances and other 'connections' through your private profile, it should be made clear to them that social and professional relationships should not be mixed. 3 The patient, where appropriate, should be directed to your professional profile and to the professional bodies' websites and associated social media platforms.

Although the same expectations of patient confidentiality that exist offline apply to online behaviour, there are unique challenges to protecting patient privacy on the internet. 1 Privacyencrypted professional or institutional accounts must be used for the purposes of emails and other online communication with patients. Such online correspondence should be documented and archived in the patient's official medical records, either in summary or by inclusion of the entire transcript, as it would be for any other medium. Online communication with patients should only be used in the context of a pre-existing surgeon-patient relationship and should act to supplement, rather than substitute, a face-to-face clinical encounter. 6 It has become commonplace for surgeons to use social media sites for educational purposes and to obtain advice from colleagues regarding complex clinical problems. This involves sharing surgical information including case scenarios, clinical and operative photographs, or radiographic images. As with all other use of clinical content, these materials should only be used once written informed consent from the patient or surrogate has been obtained. Publication of clinical content or images, in whichever online or offline medium, is under the regulation of the Caldicott Guardians in the United Kingdom and the legislation of the Health Insurance Portability and Accountability Act in the United States. All patient identifiable data should be removed, and this extends to images that allow identification of the patient, such as unique piercings and tattoos. While deidentifying patient information is mandatory, surgeons must be cognizant of the context of the information available online. Even images that omit identifying features may inadvertently allow a link to a specific patient; for example, your location or institution may be embedded within photographs and other contents, news media and publicly available vital statistics. 1 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. 3 The use of closed groups, i.e. groups that are by invitation only and not accessible to the public, offers an additional layer of privacy that allows a more liberal exchange of clinical information and opinion that would be permissible in an open forum. 6 Although engagement in these fora can be a useful educational tool and benefit patient care, caution should still be exercised because privacy is never absolute and security is never impenetrable. It is also necessary to uphold the usual professional standards of decorum and respect for the patient and to refrain from comments on a patient's behaviour, history, or characteristics that may be perceived as derogatory or disrespectful. 6

Respect for colleagues Social media offers an unprecedented opportunity for surgeons to connect across the globe in real time for personal and professional support. A recent study found that social media serves as a valuable tool to enhance the networking and mentorship of surgeons, particularly for women in surgical specialties who may lack exposure to same-sex mentors at their own institution. 8 The value of this type of support network is even more appreciated in remote and rural surgical practice.

While there are definite positive aspects of social media, there are users whose online behaviour has a negative impact on their colleagues, the surgical community, and the medical profession as a whole. The seemingly faceless anonymized online existence on social media unfortunately has facilitated propagation of extremist opinion and fuelled unsolicited trolling and cyberbullying. The GMC Good Medical Practice states that 'doctors must treat colleagues fairly and with respect'. 3 This covers all situations and all forms of interaction and communication. 3 Bullying, harassment and undermining behaviour must not be tolerated. Gratuitous, unsubstantiated or unsustainable comments must not be made about individuals online. Although it is acceptable to disagree with colleagues and have a healthy debate on social media, such posts should be respectful, collegial and reflect positively on the profession. 1 If you see colleagues behaving in an unprofessional or inappropriate manner, you have a responsibility to bring this to their attention discreetly so that they have an opportunity to reflect and take action. If the colleague does not make amends and you believe the breach of the code of conduct is serious, then they should be reported to supervisory and/or regulatory authorities. 5, 9 Users of social media should be mindful that postings online are subject to the same laws of copyright and defamation as written or verbal communications, whether they are made in a personal or professional capacity. 3, 10 Relationship with your employers Many educational and medical institutions have specific policies governing social media use by employees. These protocols may place additional restrictions on online activities and describe boundaries that should not be breached in order to avoid disciplinary action and penalties. Surgeons should be familiar with and abide by these policies as ignorance is rarely an excuse. Screening online profiles is an increasingly common practice during recruitment and hence surgeons must be aware that their online behaviour may influence employability and have consequences while employed. 1,6 Although a strong favourable social media presence might be an attractive asset to an employer, content that portrays a surgeon in a controversial light can have a detrimental impact on their career and professional standing. It is crucial for surgeons to avoid posting content that have negative or unintended consequences in the workplace. 1

The internet provides an abundance of healthcare-related resource and advice from all sorts of outlets. This readily available information accessible by a click of a button can be both helpful and confusing for our patients or potential patients. As we are all too painfully aware of the phenomena of 'fake news' and 'sensationalism', it can be notoriously challenging for some lay public to decipher what is satire and falsehood and what is evidence-based science and medicine. The engagement of surgeons in social media can maximize quality patient care by disseminating credible 'filtered' or 'censored' information regarding existing treatments by experts. 11 The contribution of the surgeon's expertise, insights and experience can also help dispel myths and misinformation and reject unsubstantiated advice and deleterious treatment suggestions.

As creators of 'fake news' become more sophisticated, even some medical professionals and surgeons can be deceived. It is therefore important to resist taking what is being projected at its face value and this extends to the increasingly popular infographics and visual abstracts. Surgeons must be disciplined to trace the origin of the post and ensure that the visual abstract is in fact released by a reputable journal and that the original article has gone through the rigorous process of peer review, copyediting and proofreading. The easily digestible visual abstract is designed for quick dissemination with maximal impact and take advantage of our ability to quickly interpret visual data. It is understandable that given such a user-friendly interface for the busy surgeon to simply accept and be influenced. Surgeons must always return to the original research article for a full critical appraisal and remember that a visual abstract is not a substitute for reading the article. Just as any single article should not change one's practice, a visual abstract alone should not influence clinical decision making or opinion about the paper. 12 Surgeons must also be aware that just because a visual abstract or content has been widely shared or retweeted on social media PROFESSIONAL DEVELOPMENT SURGERY xxx:xxx platforms, it does not necessarily mean that it is of high quality. In the same way that there are limitations to the traditional journal impact factor, a high altmetric score is merely a summative indicator of attention, dissemination, influence and impact but is not itself evidence as such.

Careful consideration should be given to the decision of partaking in dissemination of a piece of social media content, particularly whose original poster was not yourself. Such act of circulating information implies your open endorsement, as a surgeon and a professional, of that social media user and that specific piece of social media content that you shared. Disseminating mistruths and misinformation, even by mistake, can be dangerous. Retraction not only is embarrassing but is often suboptimal given the speed at which information can travel with social media to a potentially infinite and impressionable audience. It is prudent to recognize that actions online and content posted and shared can undermine the public trust in the medical profession.

Public health and awareness campaigns Social media provides a powerful platform for public engagement in promoting public health and awareness campaigns. The most topical example is the educational contents on social media emphasizing the role of personal hygiene and social distancing in controlling the spread of COVID-19 during the pandemic. Another example is the introduction of an optimized social media intervention with the aim of improving organ donation awareness among minorities in the United Sates. 13 While such activities are generally well-intentioned patient-centric initiatives, only a fine line distinguishes advocacy from paternalism. With the rapid capricious developments of social media, surgeons must be actively involved and gauge the mood of the public to avoid any misconceptions of coercion and lack of autonomy. In addition, when posting material online, you should be open about any conflict of interest and declare any financial or commercial interests in healthcare organizations or pharmaceutical and biomedical companies. 3, 10 It is, as always, your responsibility to avoid even the appearance of impropriety. If it is not feasible to include a relevant conflict of interest within a post, then the post should not be made. 1

Professionalism is the basis of a surgeon's contract with society. 14 The GMC guidance on doctors' use of social media states 'If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represents themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely'. 3 All content posted on social media, regardless of whether it originates from a surgeon's personal or professional account, should be regarded as visible to the public. 6 Privacy settings for each of your social media profiles should be reviewed regularly and conservative privacy settings should be adopted to safeguard personal information and content. 3, 10 It is important to bear in mind that even if using the most stringent privacy settings, it may not be possible to control how widely information is shared and that comments may be taken out of context. 10 There is no absolute guarantee that deleting information offers protection and it is not unreasonable to assume that any information posted online will remain available in perpetuity and might be accessed by anyone at any time. 1 Professional online profiles should be regularly updated to provide contact information and accurate representation of the surgeon's credentials. Surgeons are encouraged to periodically self-audit and take measures to ensure that the information presented is accurate and professional. 15 Establishing online professional profiles and engaging proactively in social media allow better control over your online footprint, whereas failure to update your professional profile and engage in social media might come across as being out of touch.

Social media has become a ubiquitous part of modern life and is a staple of contemporary communication. It is our professional duty as surgeons to become adept users of the different social media platforms so that we can interact with patients, colleagues, professional societies, and regulatory authorities in an ethical and professional manner. There are many, often hidden, pitfalls with use of social media that we must be aware of and safeguarded against. Thoughtful foresight and extending traditional expectations of professionalism to online behaviour, content, and engagement remain the most valuable guide using social media.A

Best practices for surgeons' social media use: statement of the resident and associate society of the American College of surgeons

GMC

AMA

Professional guidelines for social media use: a starting point

Social media in the mentorship and networking of physicians: important role for women in surgical specialties

ANZ

Social media is a necessary component of surgery practice

Seeing is believing: using visual abstracts to disseminate scientific research

A data-driven social network intervention for PROFESSIONAL DEVELOPMENT SURGERY xxx:xxx improving organ donation awareness among minorities: analysis and optimization of a cross-sectional study

Social media and the surgeon

Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards