How much of a social media profile can doctors have?BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e440 (Published 23 January 2012) Cite this as: BMJ 2012;344:e440
Professionalism and social media can be an uneasy mix. In the police force, Freedom of Information data have shown that, in the past four years, two officers have been sacked, seven resigned, and over 150 been disciplined for placing “inappropriate” photographs or comments online.1 Nurses have been sacked after making comments about patients and colleagues online,2 posting photographs of themselves exposing their breasts while in uniform,3 and putting pictures of patients online.4 In the United States, four nursing students were expelled after putting a photograph of themselves with a human placenta on Facebook5; and, in Sweden, a nurse has been disciplined for putting photographs from the operating theatre on the same social networking site.6
Doctors have not been immune. In the UK there have been several high profile incidences of tweets or online interactions that have ended up in the lay press; one Scottish junior doctor was controversially suspended over comments made about senior doctors on a website for doctors and students.7
Meanwhile, the BMA has published guidance for doctors and medical students on how to use social media,8 and the General Medical Council, the UK regulator, is currently consulting on it. There are clear things that doctors should not do, whether online or not—namely, break confidentiality or perform illegal acts. The internet means that it is possible to communicate quickly with specialists or colleagues locally or distantly. But while email is private and can be sent with a high level of security, the trend for online discussion through blogs, discussion forums, or Twitter means that more people can view what doctors are saying to each other about clinical or other matters.
Some websites aimed at doctors—for example, Superego Cafe, the BMJ Group’s doc2doc, and doctors.net—have specific forums for discussing clinical cases. On doc2doc members need to provide proof of relevant medical qualifications before gaining access to a closed clinical forum. But this isn’t the case everywhere. A recent case discussion on a Superego Cafe forum, aimed at psychiatry professionals, contained several specific details that may have made the patient identifiable not only to herself but also to her friends or community. The forum could be accessed and joined by a simple process of obtaining a password and does not require the user to be medically qualified, and casual browsers are allowed limited access. Is this wise?
Godwin Busuttil is a barrister specialising in media law at 5RB Chambers, Gray’s Inn, London, and is a legal adviser to the BMJ. He has several concerns about the use of online media by doctors. “This is a further example of a wider phenomenon. People feel disinhibited when they go online. A doctor traditionally may have discussed things—such as the subject of the blog—with other doctors in the hospital canteen or on the phone but would not have dreamt of putting them on a message board where everyone could read them. If a doctor is talking to a colleague, it’s done in a collegial way, in the spirit of professional inquiry. No harm is likely to be done, and there may actually be a benefit to the patient. But doing it online gives rise to all sorts of concerns about patients’ privacy.” In the Superego Cafe case, “Although the doctor doesn’t name [the patient] the facts are distinctive, and she could be identifiable to people who know her. On the other side of the equation, how likely is it that people who know her personally, as opposed to health professionals, are going to be accessing this specialised sort of forum? Objectively, the risk of disclosure of sensitive information would seem limited, but that is not to say that the patient would not be upset if she found out such disclosure was going on.”
Would limited risk of disclosure be enough to protect a doctor writing about a case or asking for advice from colleagues online? “No,” Mr Busuttil says. “The fact that the doctor seems in a genuine way to be seeking advice from other doctors might support a public interest defence. Objectively it reads like a canteen-type of conversation where the doctor is genuinely trying to get a second opinion. And there is of course a public interest—trying to improve care—in that, and that can provide a defence in law to a claim for breach of confidence or misuse of private information. However, the doctor in posting this material online is—but may not realise that he is—acting as a data controller for the purposes of the Data Protection Act 1998.”
The act covers personal data relating to an individual who can be identified either from that data or from other information held by the data controller. The Department of Health says that this includes “any expression of opinion about the individual.”9 The handling of such data must be consistent with duties of confidentiality to the patient if the “processing” is to be lawful. Health professionals who do not comply with the act can be sued for damages and have to pay the costs of the claim.
There are many medical, nursing, and paramedical blogs that offer anonymous insights into frontline NHS care—is this safer? Mr Busuttil doesn’t think so. “If someone has an issue with what an anonymous poster or blogger is writing, whether that person is a doctor or not, it’s relatively easy to get an order from the court against the host of a website or even Twitter requiring them to identify the person in question. My advice is that it’s ill advised for a doctor to blog anonymously as it may encourage even greater disinhibition.”
The hinterland between personal and professional is raised in issues such as “friending” patients on Facebook. This has been discussed by the BMA, which recommends doctors do not accept “friend” requests from current or former patients. It also reports an instance of a patient attempting to make unwanted social contact with a doctor. The BMA acknowledges that many doctors may choose to share some personal information with patients, but this can be controlled in the consulting room in a way that is not possible online.8 The American Medical Association suggests that doctors should separate professional and personal content online and “must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.”10
So does a doctor have to adhere to professional responsibilities and standards online at all times—even if communicating only to friends or family? Can a doctor act as a private individual online when not at work? A police inspector was turned down for promotion after his employers decided that his colourful—but legal—descriptions of his private life could “bring the force into disrepute.”11 Is this fair—and what kind of online presence can doctors ethically have?
The GMC ran an online poll in 2011 asking if it “should regulate doctors’ lives outside medicine.” Of the 1167 respondents, 1100 (94%) said that it should not. In response, the GMC quoted Good Medical Practice, which states: “You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.” It went on, “Most commonly fitness to practise cases citing this paragraph arise where doctors are convicted of criminal offences, accept cautions or equivalent sanctions across the UK. But occasionally we also take action on doctors’ registration as a result of doctors’ behaviour in the public sphere, which while not illegal, may undermine patients’ or public trust in the profession. The rationale for this has always been that patients need to trust their doctors absolutely. Many patients will be vulnerable when they seek medical care and need to be able to trust doctors implicitly.”12
Asked to clarify the demarcations between the personal and the professional, Niall Dickson, the chief executive of the GMC, said in a statement that “Doctors must make sure that their conduct at all times justifies their patients’ trust in them and the public’s trust in the profession. Doctors who comment in the public domain about their work or the provision of healthcare must be mindful of patient confidentiality and treat colleagues with respect. We want to provide helpful advice to the profession so we will shortly be asking doctors and patients for their views on new draft guidance on the use of social media.” The GMC confirmed that it has already investigated complaints about doctors’ online activity and expects to do so again. What is less clear is where a line can be drawn around a doctor’s ability to interact with others as a normal citizen rather than with professional responsibility—the types of activity that may lead to patients not “trusting doctors implicitly” will vary from person to person.
Roger Smith is director of JUSTICE, a law reform charity concerned with human rights. He thinks there is a balance to be struck. “Do I care as a patient that my doctor is so infuriated by politicians that he discusses them with rude language? No.” European citizens are protected under the European Human Rights law, which allows for people to have private lives. “Article 8 of the European Convention on Human Rights gives you the right to privacy, but there are exceptions. It’s legitimate for the GMC to be concerned with the trust of the patient, but there would have to be a link between the personal behaviour of a doctor and the potential to lose the trust,” says Mr Smith, “The doctors’ act under question should be linked to the consequence and the relevance of it for the patient. In addition, if someone is going to be deprived of their livelihood, the punishment would have to be proportionate. There probably is no alternative but to say this has to be considered on a case by case basis. For example, take an online nude photograph. Well, there’s nudity and there’s nudity—by itself it wouldn’t necessarily be a problem. It would depend how lewd it was—there’s a difference between japes and, say, objectionable photographs of genitals that could be really offensive to patients. It would also be dependent on how far they were circulated round the public. And then, a successful action against a doctor would depend on the line of causation—could the photo foreseeably lead to a loss of patient trust?”
Mr Busuttil also cautions about the liberal use of online media more broadly. “Quite a lot of people, not just doctors, have been caught out by posting online—for example, on Facebook— material deemed by others, especially employers, to be inappropriate. People tend to think of what they post on Facebook as purely their own private business and not to do with their professional life. But in the real world such distinctions can’t be drawn quite so easily, and employers—rightly or wrongly—may regard something their employee has posted on Facebook as completely inappropriate.”
But we must not be overly cautious and miss the richness of communication and interaction that social media can offer. Doctors, like other citizens, are entitled to express opinions online, and one effect of the undoing of the medical god-complex has been to humanise medicine and populate it with doctors who are fallible but professional. The GMC’s new guidance should reflect the changing, more mature role of doctors in society.
Cite this as: BMJ 2010;341:e440
Competing interests: The author has completed the ICJME unified declaration from at www.icmje.org/coi_disclosure.pdf (available on request from her) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.