The social media dilemma

Should you friend your patients? Is it OK to post about the #MeToo movement? What about discussing cases online, even in the most generic terms? Leaders in academic medicine are rolling out guidelines to help students navigate these and other tough questions.

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It was September 2018 when Jacqueline Harris, a fourth-year student at Vanderbilt University School of Medicine, decided to change her social media presence pretty dramatically. 

She took steps to make it harder to find her on Facebook and switched her Instagram and Twitter accounts to private. 

Harris’s decision was sparked by her upcoming residency applications: While she has never made a habit of posting controversial material, she couldn’t risk having her career derailed by the wrong photo or comment.

“I’ve heard institutions will look you up to get a better sense of who you are as a person,” Harris says. “Who’s to say something I think is funny or that I like isn’t going to be taken the wrong way?”

She adds, “My biggest fear would be something that I perceive as empowering or impactful would be misconstrued by someone who has influence on my career and where I go.”

Social media is a difficult and risky world to navigate, and medical students face a slew of complicating factors. They must work to protect their professional personas and keep patient information safe. Still, many want the freedom to maintain their individuality and participate in online advocacy movements like #MeToo and “black men in white coats,” which works to diversify the medical community. They want to connect with patients, but they don’t want to be unprofessional. And to make matters more difficult, there are almost no hard-and-fast rules to guide them. 

“My biggest fear would be something that I perceive as empowering or impactful would be misconstrued by someone who has influence on my career and where I go.”

Jacqueline Harris
Vanderbilt University School of Medicine

“Students struggle with what the standard is. They want rules,” says Danielle Dickey, EdD, director of academic affairs for Texas A&M Health Science Center College of Medicine. “But other than HIPAA, there really aren’t any.”

That’s why a growing number of medical schools nationwide are adding content to the curriculum to incorporate best practices around social media use, recognizing the unique position that medical students are in when it comes to protecting patient privacy and creating a professional web presence that upholds the ethical standards of the medical profession, while still allowing students to advocate for social justice issues.

Protecting patient privacy

The American Medical Student Association (AMSA) does provide social media guidelines on its website, though they are somewhat vague. The AMSA instructs medical students to: 1) Be professional, 2) Be responsible, 3) Maintain a separation from patients, 4) Be transparent and use disclaimers, 5) Be respectful, 6) Follow copyright laws, 7) Protect patient information, 8) Avoid politics, 9) Comply with all legal restrictions, and 10) Be aware of risks to personal privacy and security. 

Of course, there is the HIPAA privacy rule, which was the first federal protection for the privacy of personal health information. The standards do apply to social media platforms, but HIPAA was enacted long before social media networks came into play, so there are no specific rules to serve as guidance.

Now, medical school instructors are taking it upon themselves to teach students the dangers of violating HIPAA when posting about patients. 

Students at Harvard Medical School, for example, are told to ponder a question in their first week. Which is worse: posting a sweet patient story on Facebook that could lead to identification of the patient, or posting denigrating words about a patient that keeps him or her anonymous?

The correct answer? They’re both problematic.

“Even if the post is touching and shows empathy, it’s not the right forum to be doing that,” says Anthony Breu, MD, course co-director for the medical ethics and professionalism curriculum at Harvard. “And making denigrating comments, no matter how anonymous, reflects poorly on the profession.”

And while a student might understand this, there are other boundary issues to grapple with. For instance, is it ok to friend patients?

Most instructors answer this with a resounding “no.”

“We try to discourage students from engaging in social media with their patients,” says Gerardo Maradiaga, MA, a clinical ethicist at Wake Forest School of Medicine. That’s in part because connecting online with patients could trigger unanticipated privacy issues.

To drive home his point, Maradiaga poses a hypothetical scenario: A student becomes Facebook friends with a patient who says she has quit smoking. But the patient later posts a photo with a cigarette on her page. How will this information affect the way in which the student interacts with the patient?

“Is it ethical to access information that way?” Maradiaga asks. “And what does it do to the patient-student relationship? We talk about how that could feel like an invasion of their privacy and it can shake that trust.”

Maintaining professionalism

For some students, acceptance into medical school means a complete remaking of their social media presence. Perry Tsai, MD, PhD, national president of the AMSA, recommends that students create separate personal and professional Facebook, Twitter, and Instagram accounts. He also recommends that students limit their posting to the medical field and advocacy initiatives on their professional accounts.

“I think promoting things that happen within your profession or within your institution is always great,” Tsai says. “Maybe professional achievements that your colleagues might have or research that’s come out.” 

In addition to celebrating progress in medicine, students can use their social media accounts to connect with people who’ve had similar experiences. 

“There are a lot of things that are challenging in the profession,” Tsai says. “While struggling with the stress of all the things we need to get done, we’re dealing with things like death and disability, dying and disease. Social media is sometimes a way to share those experiences in a general way.” 

Texas A&M College of Medicine is working to steer students in the right direction. The college touches on social media issues both in the first and fourth years, encouraging students to evaluate their internet personas. In the first year, they hear from an ethicist and break into groups of 10 or 12 to discuss case examples. In the fourth year, they have a professionalism module that covers 10 musts and must nots, including social media topics. Internet practices also pop up at various times throughout the program, when ethics and professionalism are addressed.

All the while, instructors stress that judgments about what is and isn’t appropriate are almost entirely subjective, so it's better to be safe than sorry. 

“We drill into their heads that professionalism begins the minute they step on campus. It doesn’t take a license.”

David Lambert, MD
University of Rochester School of Medicine and Dentistry

“The biggest underlying premise is there’s going to be a lot of judgment about what a person puts out there, and perception is reality,” Dickey says. “Their employers and their teams will have those judgements. If someone thinks there’s a problem, there’s a problem.”

At the University of Rochester School of Medicine and Dentistry, students can ask questions about online behaviors through a school intranet site. The portal allows anonymous queries, so students don’t have to fear risking embarrassment. 

Students also receive repeated instruction on internet conduct, starting during orientation week, says David Lambert, MD, senior associate dean for medical student education at the school.

“We drill into their heads that professionalism begins the minute they step on campus,” Lambert notes. “It doesn’t take a license.”

The upsides of social media

Despite the professional dangers it poses, the internet can be a place to form connections and dip into social justice advocacy work, says Jeanne Farnan, MD, MHPE, associate dean of evaluation and continuous quality improvement at the University of Chicago Pritzker School of Medicine. 

“We don’t want to dampen their voice,” she says of students. “We just want them to use it in a professional way.”

“Our students are super active in issues around social justice. We don’t want to come at this conversation with ‘The 10 Commandments of Facebook.’ We just want them to recognize there can be consequences for what they post.”

Jeanne Farnan, MD
University of Chicago Pritzker School of Medicine

Students and doctors have used social media to advocate for diversity in hospitals, gender equality, and universal health care, among other causes. There are Twitter chats specifically dedicated to uniting groups within the medical community, including a #WomenInMedicine chat. In addition, medical students have taken to social media to get their med school questions answered — Farnan says she’s advised students on Twitter whom she has never met. The @AAMCPreMed account helps aspiring doctors know what to expect from medical school and residency and uses hashtags to advocate for causes, including #BlackMenInMedicine.

“Our students are super active in issues around social justice,” Farnan says. “We don’t want to come at this conversation with ‘The 10 Commandments of Facebook.’ We just want them to recognize there can be consequences for what they post.”

On the whole, Farnan says, students seem to be moving toward a more productive approach to social media, often using it to become better doctors, more involved peers, and stronger patient advocates.

“It’s not as much a tool to post silly pictures,” Farnan says. “It’s more an avenue to unite as a group across the country.”