The American College of Surgeons (ACS) Committee on Ethics developed the following Guidelines for the Ethical Use of Social Media by Surgeons. The ACS Board of Regents approved the guidelines at its February 8−10 meeting in Chicago, IL.
Social media has become a ubiquitous part of modern life. As such, surgeons need to know how to use this platform successfully to interact with colleagues, patients, professional societies, and regulatory authorities in an ethical and professional manner, thus protecting the best interests of all parties including themselves. The following guidelines do not cover every possible interaction, but are intended to provide guidance as to how to have an online presence and adhere to the ACS Code of Professional Conduct.
Surgeon-patient relationship
It is important not to blur the boundaries between professional and personal relationships with patients, which may happen more easily online than in other interactions. Accepting “friend” requests on Facebook, for example, and other direct relationships on social media platforms used to share personal information (rather than websites explicitly intended for disseminating health care information) should be discouraged. One option is to maintain separate professional and personal profiles and accounts, and only use the professional account for interactions with existing or potential patients. Interactions on a professional account should follow the guidelines set forth in this statement.
Social media also affords the surgeon the ability to access information about a patient’s health care or other behavior (smoking or alcohol consumption, for example) that might affect treatment plans. This information theoretically might benefit the patient’s care, but there are drawbacks to using this information within the context of a surgeon-patient relationship. First, there is the need to reveal the source of the information in a sensitive manner, without destroying the trust of the surgeon-patient relationship. Second is the risk of tipping over into curiosity, voyeurism, and invasion of privacy, which can destroy the relationship with the patient and also reflect badly on the institution and even the entire profession. Therefore, “patient-targeted Googling,” as this practice is known, is strongly discouraged.
Online communication with patients
Privacy-protected professional/institutional accounts or web-based platforms should be used for purposes of e-mail and other online communication with patients. These accounts and platforms should only be used within the context of a preexisting surgeon-patient relationship and should augment, rather than substitute for, face-to-face communication. Documentation should be maintained as part of the official medical record, as it would be for any other medium.
Requests for surgical information online from a prospective patient should be treated with care; the limitations of online communication make it an inappropriate substitute for an initial face-to-face visit. An appropriate response to a request for surgical information through social media would be a recommendation to seek a referral from the patient’s primary care physician to a surgeon for a formal, in-person evaluation of a clinical concern. In some situations, where substantial geographic distance creates an impediment, an initial, face-to-face contact may be initiated via secured telemedicine communication tools.
Privacy concerns
Social media provide opportunities for sharing surgical information with colleagues and patients for educational purposes; examples include case scenarios, clinical photographs, or radiographic images. As with all other uses of clinical content or images, these materials should be shared only with informed consent (preferably in writing) from the patient or surrogate. All protected health information (PHI) and personal identifiers should be removed. Even with patient consent, images that allow identification of the patient, such as facial features and unique tattoos, should not be disseminated on social media.
Unlike in conventional media, images once shared online cannot be subsequently retracted or removed. Although the patient may have consented to use of these images at the time of interaction, there is the potential for the patient to subsequently regret this decision or for the images to be altered and used out of context by other persons. Minors whose parents have provided permission for use of their child’s image may subsequently choose not to have the image widely shared, especially as it may affect the child’s online presence years into the future.
Even images that omit identifying features may inadvertently allow a link to a specific patient. For example, a bloody trauma bay (even without a patient) after a major trauma incident or an unusual injury (samurai sword to the heart) in conjunction with the timing of the post will allow many people in that institution or community to accurately identify the patient or incident involved, as has happened in several well-publicized instances that have resulted in suspension or termination of the employee who posted the content. A waiting period of at least several weeks prior to posting and concealment of clinical details that are unusual or could be considered newsworthy will reduce the likelihood of patient identification and inadvertent breach of privacy laws.
Social media postings also should respect intellectual property and copyright laws, and surgeons should follow standard procedures for obtaining permission for reproduction of artwork, images, and so on, as with any other publication modality. This standard does not apply to reposting of content already within the public domain, such as news reports, blogs, or journal articles.
Social media postings that include images of individuals other than patients who interact with the surgeon in a professional context—colleagues, staff, residents, or medical students, for example—should be posted only with the consent of these individuals.
Patient education
Social media has emerged as a valuable tool for sharing information regarding health concerns among patients themselves (crowdsourcing or crowdhealth) as well as through established health care entities. Surgeons should be aware of, and recommend, reputable online peer-reviewed or quality-controlled sources for patient information in their areas of practice.
Surgeons may engage in discussions regarding health topics online through dedicated message boards, forums, or open social media; however, they should use caution and only submit general statements rather than specific recommendations that the reader could construe as health care advice. Blanket assertions on a social media profile (such as, “tweets do not constitute health care advice”), although widely used by health care professionals, provide neither legal nor ethical immunity if an interaction with a layperson evolves into what either party could consider to be a therapeutic relationship.
Surgeon education
Social media has emerged as a powerful tool for health care professionals to share information and obtain advice from colleagues regarding complex clinical problems. Many closed groups, not accessible to the public, are hosted on larger social media platforms (such as Facebook, WhatsApp, ACS Communities) and allow surgeons around the world to exchange information and ideas. In these situations, a layer of privacy exists that allows freer exchange of clinical information and opinion than would be permissible in an open forum. Although engagement in these fora can be a powerful educational tool and benefit patient care, caution should still be exercised when sharing patient information because privacy is never absolute. It also is necessary to maintain usual professional standards of decorum and respect for the patient and to refrain from comments on a patient’s behavior, history, or characteristics that may be perceived as derogatory or disrespectful.
Surgeon’s online persona and professional representation
All content posted on social media, regardless of whether it originates from a surgeon’s professional or personal account, should be regarded as visible to the public, including patients, employers, professional societies, and state and federal regulatory authorities, such as licensing boards. As professionals, the public views our actions as representative of our profession—hence, the development and upholding of standards of professionalism by medical and surgical organizations. Online content also is subject to the same defamation laws governing libel and slander as other public discourse.
Content that may be considered appropriate in a closed, informal setting (such as a “roast” of a retiring surgeon, a parody item performed by medical students during a talent show) may be viewed very differently by the general public, creating a negative impression of the individual, his or her institution, and the entire profession. An image of a surgeon posing with a large amount of skin and tissue removed during an abdominoplasty operation, while not objectively wrong or containing patient identifiers, was pilloried on both social media and subsequently mainstream media as an inappropriate “surgical selfie” for its resemblance to trophy photography. While this perception was likely not the surgeon’s original intent, this example demonstrates how easily the boundaries of what is considered acceptable behavior by the public may be inadvertently crossed.
Unsavory postings may affect the surgeon’s ability to train residents, maintain employment, or practice in a community. Images of physicians intoxicated, using illicit drugs, or posing with weaponry or surgical specimens, for example, have resulted in formal censure by medical boards and employers. The same standards that would be expected in formal advertising or conduct at a professional society meeting apply to online content. Therefore, several physician organizations have recommended a “pause before posting” approach and that recommendation is strongly endorsed here.
Professional online profiles should be regularly updated and provide contact information, accurate representation of the surgeons’ credentials, and a description of services offered. Surgeon profiles are affected not only by their own postings, but also those of their patients, especially through online physician evaluation sites. These sites often appear high on the list of results when surgeons’ names are searched through Google or other search engines. Therefore, it is prudent for surgeons to play an active role in maintaining their own online presence by maintaining official professional profiles that appear first in a search. Regular “self-audits” to identify misleading or inaccurate information should be conducted; in some cases (although not all), an opportunity is provided to correct information or request a retraction.
Surgeon as employee
Many institutions now have specific policies governing social media use by employees. These protocols may go above and beyond the guidelines in this statement and place additional restrictions on online activities in which employees, including surgeons, may engage. Surgeons should be familiar with and abide by these policies. Failure to do so has resulted in penalties, including dismissal. Screening online profiles is now a standard part of the interview process for new recruits, so the potential for future impact should also be considered. As the online presence of surgical societies and other organizations increases, participants should also be aware of additional policies by which they may be required to abide.
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