Patients have gone online, digital natives are entering medical schools and regulatory bodies, like the General Medical Council in the UK, are scrambling to respond to the impact these changes are having on medical professionalism.
The possibilities for enhanced learning, better communication and higher quality care are vast. Social media, which has been described as the greatest revolution since the Gutenberg printing press, can provide patients with faster and easier access to doctors and it can help health care professionals disseminate important public health messages effectively and efficiently. Social media also allows physicians to observe and counsel patients about their risk taking behaviour and it lets psychiatrists digitally track “high risk” patients in order to intervene in an emergency. Heath care professionals can also use online social networks to crowdsource answers to complex clinical questions.
But the potential pitfalls associated with social media are equally vast and a number of doctors and medical students have already come a cropper as a result of their unwise use of Facebook, Twitter and other forms of social media.
Confidentiality is one major area of concern. Hippocrates taught us that privacy matters to the doctor-patient relationship, but even that wise sage could not have imagined the complex blurring of boundaries between public and private life that has occurred as a consequence of the digital revolution in healthcare.
One point to bear in mind here is the extent to which users of social media are now connected to other people. This is best illustrated by the concept of “degrees of separation”. Frigyes Karinthy, a Hungarian author and playwright, introduced the concept of six degrees of separation in 1929. In essence his idea was that everyone on planet earth was no more than six acquaintance links apart. Whether this was true in 1929 is unclear, but a study carried out in 2011 suggests that the degree of separation, at least for users of Facebook, is now about half what Karinthy thought it was.
This matters because a comment about a patient posted by a health care professional on their Facebook page may quickly lose its anonymity because of the size of their friend networks. This is especially true if “friends of friends” can access the posts.
A similar problem with confidentiality arises when health care professionals refer to patients on “open access” medical blogs or Twitter accounts. Remarkably, a recent study found that 17% of medical blogs include sufficient information for patients to identify themselves or their physicians and the same study found that a small number of these blogs included recognisable photographic images of patients.
Another major area of concern relates to the maintenance of proper boundaries between professionals and patients. Patients often disclose a great deal of non-clinical information to health care professionals and it is not uncommon for professionals to partially reciprocate. But patients can now find out far more about their doctors’ personal lives, including information about their sexuality, their drinking habits and their political views, by simply searching for this information online. This is not necessarily problematic, but access to this kind of information could undermine the doctor-patient relationship.
Health care professionals also increasingly use the internet to search for information about their patients. There are often very legitimate and ethically unproblematic reasons for doing this. For example, doctors might be able to identify unconscious patients by conducting a simple online search. However, it is less clear whether it is ethically acceptable for health care professionals to use the internet to check whether patients are driving against medical advice or using recreational drugs. Obviously, searching for information about patients out of sheer curiosity or sending Facebook friend requests to patients for voyeuristic reasons is beyond the pale. But there is a lot of grey area here and further research is needed to discover what patients think about some of the more controversial forms of “digital medical snooping”.
Health care professionals also use social media to vent their frustrations about their patients, colleagues and working environment. Some of this venting provides a window into the reality of medicine in the 21st century and it may be argued that this serves an important public interest. However, if the posts include unjustified statements that harm reputations then charges of defamation may follow. Likewise, if the comments constitute “vulgar abuse”, negative professional and contractual repercussions may occur - as a junior medical officer who used “scatological” language to describe a senior colleague on a social network forum quickly found out when he was temporarily suspended from work.
Thankfully, many medical organisations have now published useful guidance to help doctors navigate the kind of professional and ethical pitfalls described above. But these are early days in the digital health revolution and, as new technologies come online, physicians will have to exercise a considerable amount of their own professional judgement to determine what is, and what it not, acceptable digital behaviour.