How do We Define Professional Physician Behavior in Social Media?

Editor's note: Mark Ryan, MD is a family physician practicing in Richmond, VA and a member of the External Advisory Board for the Mayo Clinic Center for Social Media. One debate that is often raised about the use of social media by physicians is what is considered professional versus unprofessional behavior.  In this article, Dr. Ryan discusses his thoughts on the topic.

Recently, the issue of physician professionalism while using social media has been a focus of much discussion.  In May, Dr. Bryan Vartabedian ("Doctor V"; on Twitter as @Doctor_V) wrote on his blog about an exchange that he defined as unprofessional.  If you read Dr. V's post, and the subsequent comments, it is clear that although many people agreed that the exchange Dr. V described was unprofessional, this opinion was not unanimous and the debate was long and involved.  In fact, some of the commentators wrote their own blog posts opposing Dr. V's view: examples noted here and here.  Recently, an article in the American Medical Association (AMA)'s American Medical News article about the issue of online physician anonymity sparked a new round of discussion about online physician professionalism including blog posts byDr. Kelly Sennholz, Dr. Jen Gunter, and a quick post from me.

It is evident from these few examples that the issue of online professionalism has not been defined, and it is presumptuous for me to believe I can do so single-handed.  However, I wanted to take some time and review the definitions of medical professionalism and think a bit about how they translate into online interactions and social media.

I found a number of definitions of what constitutes medical professionalism.  One of the most useful and comprehensive definitions I found was proposed by Dr. Herbert Swick and published in Academic Medicine in 2000.  According to this definition, the key characteristics of medical professionalism are:

  • Physicians subordinate their own interests to the interests of others.
  • Physicians adhere to high ethical and moral standards.
  • Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served.
  • Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness.
  • Physicians exercise accountability for themselves and for their colleagues.
  • Physicians demonstrate a continuing commitment to excellence.
  • Physicians exhibit a commitment to scholarship and to advancing their field.
  • Physicians deal with high levels of complexity and uncertainty.
  • Physicians reflect upon their actions and decisions.

In 2002, the Annals of Internal Medicine published a new physician charter for physician professionalism in the new millennium. (pdf link)  This charter, which was adopted by various physician organizations, includes three fundamental principles:

  1. Principle of primacy of patient welfare.
  2. Principle of patient autonomy.
  3. Principle of social justice.

Along with these three principles, the charter defines the following professional responsibilities:

  1. Commitment to professional competence.
  2. Commitment to honesty with patients.
  3. Commitment to patient confidentiality.
  4. Commitment to maintaining appropriate relations with patients.
  5. Commitment to improving quality of care.
  6. Commitment to improving access to care.
  7. Commitment to a just distribution of finite resources.
  8. Commitment to scientific knowledge.
  9. Commitment to maintaining trust by managing conflicts of interest.
  10. Commitment to professional responsibilities.

Last in this brief survey of physician professionalism, it is worth looking at the AMA's own Declaration of Professional Responsibility. (pdf link) Although the AMA does not represent a majority (or even a plurality) of American physicians, it is an organization to which others look for guidance.  This Declaration dates from 2001, and calls on physicians to uphold the following values:

  1. Respect human life and the dignity of every individual.
  2. Refrain from supporting or committing crimes against humanity and condemn all such acts.
  3. Treat the sick and injured with competence and compassion and without prejudice.
  4. Apply our knowledge and skills when needed, though doing so may put us at risk.
  5. Protect the privacy and confidentiality of those for whom we care and breach that
    confidence only when keeping it would seriously threaten their health and safety or that of others.
  6. Work freely with colleagues to discover, develop, and promote advances in medicine and public health that ameliorate suffering and contribute to human well-being.
  7. Educate the public and polity about present and future threats to the health of humanity.
  8. Advocate for social, economic, educational, and political changes that ameliorate
    suffering and contribute to human well-being.
  9. Teach and mentor those who follow us for they are the future of our caring profession.

Evidently, the potential definitions of physician professionalism are many and the list is expansive.  However, I do think there are common themes that become evident.  These themes include respect for patients' autonomy, individualism, and privacy; response to and concern for societal needs; embodiment humanistic values of altruism, empathy, compassion, honesty, and integrity; focus on the scientific basis of medical knowledge; accountability to peers; and commitment to professional development and competence.

I believe these definitions help us better understand what it means to be a physician in any setting, especially on the Internet and in social media.  Just as in society, we should hold ourselves--and expect to be held--to a higher standard than others.  Society expects this of us, and we should expect this of ourselves.  Therefore, we must be very careful of ever discussing real patients online.  Even if we think we have removed any possible identifying information from the post/tweet/update, I believe that patients' expectations (and the definitions above) should restrict us from discussing specific patients in public.

These definitions should also apply to those individuals using social media and the Internet anonymously.  There are many anonymous accounts on Twitter, for example, that appear to be from physicians and that violate some (or many) of the precepts put forward by the definitions of professionalism listed above.  Does that mean, though that these accounts--even if deemed unprofessional--should be targeted for criticism or for deletion?  People may use anonymous (or pseudonymous) accounts for many reasons: because they are critical of powerful organizations, because of concern for personal safety, etc.  The simple fact that they are anonymous does not, to me, define them as unprofessional.  The content that is posted is what defines them.

Indeed, it can be argued that unprofessional content can be valuable.  It can help express the frustrations of physicians working in today's health care system.  It might allow physicians to be more open and honest about their feelings than they would be if not anonymous.  It might be intended as satire or farce, and could be making points that many might agree with but are uncomfortable stating aloud.  In essence, some anonymous accounts might be the social media version of The House Of God, a book that was published under a pseudonym and was intensely critical of the current medical practice of its day and that still relevant today.

I personally believe that it is better not to be anonymous, and I will not post anything that I do not feel I can stand behind personally.  But for those who do post anonymously, we should let the content determine if the account should be ignored or if the online community should pay attention (for good or ill).  If, after following an account for some time, I feel that the unprofessional content has a valid intent or purpose then I can choose to continue to follow it.  Likewise, I can opt to tune out.  I can even choose to ignore any and all accounts that are anonymous...but that is my choice.  Even if someone posts unprofessional content, it does not mean that they do not have a right to be online and to make their voices heard.  We should let their content speak for itself: the community can decide whether their voice and their content has any value.

Only in the case of apparently egregious behavior should we act more directly.  However, the AMA's social media guidelines advise addressing this with the responsible individual first and, if no corrective action is taken, only then the behavior should be reported to the "appropriate authorities" (who are not defined, but might include the Board of Medicine or some similar body).  The Massachusetts Medical Society's social media guidelines contain similar language.  So: if we define an account or a specific post as being so grossly unprofessional that we need to act, the appropriate response is to act to address it through proper channels--not calling the behavior out in public.  Although I am not a big fan of these guidelines in that they do not give positive guidance on how to engage in social media, they do address this particular issue.  In the absence of further guidance, we may need to abide by them--whether we are posting anonymously or not.

We must also be careful calling others unprofessional unless we are abiding by the definitions above.  If we are not meeting allof these definitions, then are we also being unprofessional?  If we are not working to improve access to care and ensure a "just distribution of finite resources", then are we unprofessional?  If we accept money from PhRMA and medical device industries, are we being unprofessional?  If we do not accept Medicare and Medicaid--programs which insure our most vulnerable citizens--are we being unprofessional?  If we choose to work in areas that have a surplus of physicians, as opposed to a medically under-served area, are we being unprofessional?  If we are sub-specialists in a time when society needs more primary care physicians, are we being unprofessional?

Professionalism at all times should be our goal as physicians.  However, for nearly everyone it will be a goal, not a reality.  We will have our bad days and we will have our frustrations, but we should work to overcome them and to keep our eyes on the goal of being respected and reliable professionals.  Online, the goal should be the same.  We should be accountable for our statements: to patients, to colleagues, and to ourselves.  If someone has behaved unprofessionally, then we should address that according to the best accepted practice and pathway that we have available.   We must also model how to use social media in productive ways in order to provide positive role models for newcomers to these online communities.  Through such modeling, guidance, and effort we can strengthen professional and reliable physician voices in social media.

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What is appropriate physician behavior on the Internet and on social media?
How do definitions of medical professionalism translate into online interactions and social media?
What are the key characteristics of medical professionalism, and how do they translate into online behavior?

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