Communication Crossroads: Managing Patient Interactions, Online Personas on Social Media


It seems as though the negative stories always make the headlines: The humanitarian physician group sent to aid Haiti earthquake victims that posted not only patient photos on Facebook but also pictures of doctors drinking alcohol and brandishing soldiers’ firearms.1 Or there’s the story of the Redding, Calif.–based hospital accused of sharing a patient’s files with journalists and communicating via email about her treatment to hundreds of hospital workers.2

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

  • Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

It would also be wise to seek advice from colleagues before posting patient information, she notes.

  • Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

  • Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

  • Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

  • Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.


  1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
  2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
  3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
  4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
  5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
  6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
  7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
  8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

HIPPA Identifiers

To maintain patient privacy when specific cases are referenced in an online or printed publication, HIPPA includes a list of 18 items that can identify an individual. These “HIPPA Identifiers,” listed below, must be omitted from any online medical discussions.7

  1. Names
  2. Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
  3. Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
  4. Phone numbers
  5. Fax numbers
  6. Email addresses
  7. Social Security numbers
  8. Medical record numbers
  9. Health plan beneficiary numbers
  10. Account numbers
  11. Certificate/license numbers
  12. Vehicle identifiers including license plate numbers and VINs
  13. Device identifiers and serial numbers
  14. URLs
  15. IP addresses
  16. Biometric identifiers, including finger and voice prints
  17. Full face (or any comparable image) photographs
  18. Any other unique identifying number, characteristic, or code

FOAM Links

Some useful links to FOAM resources online:

  1. Twitter feed to stay updated on FOAM: @FOAMed
  2. Internal medicine focused FOAM project Louisville Lectures: www.louisvillelectures.org
  3. Adult emergency medicine FOAM resource Life in the Fastlane: http://lifeinthefastlane.com
  4. Pulmonary and critical-care focused FOAM resource: http://pulmccm.org/main

How Hospitalists Can Use Social Media to Improve Their Institution’s Care

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company that advises physicians about online promotion, sees social media as an opportunity for hospitalists to benefit their hospital in a number of ways.

“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”

According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.

Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH

Maybelle Cowan-Lincoln

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