AMA Journal of Ethics Formerly Virtual Mentor November 2015 Volume 17, Number 11: 1007-1101 Peer-Reviewed Article Why Can’t We Be Friends? A Case-Based Analysis of the Ethics of Social Media Use in Health Care 1009 Kayhan Parsi and Nanette Elster High-Value Care From the Editor The Era of High-Value Care 1019 Sri Lekha Tummalapalli Ethics Cases The High-Value Care Considerations of Inpatient versus Outpatient Testing 1022 Commentary by Josué A. Zapata and Christopher Moriates Grow a Spine, Have a Heart: Responding to Patient Requests for Marginally Beneficial Care 1028 Commentary by Bjorg Thorsteinsdottir, Annika Beck, and Jon C. Tilburt Cost-Consciousness in Teaching Hospitals 1035 Commentary by Maggie K. Benson Podcast Choosing Wisely: Initiating Conversation and Culture Change around Overuse of Medical Tests and Treatments Interview with Wendy Levinson Medical Education Teaching High-Value Care 1040 Aditya Ashok and Brandon Combs AMA Journal of Ethics, November 2015 1007 The Code Says AMA Code of Medical Ethics’ Opinion on Physician Stewardship 1044 State of the Art and Science The Challenge of Understanding Health Care Costs and Charges 1046 Vineet Arora, Christopher Moriates, and Neel Shah Policy Forum Repeal of the Medicare Sustainable Growth Rate: Direct and Indirect Consequences 1053 Jeffrey Clemens and Stan Veuger Increasing Cost Efficiency in Health Care without Sacrificing the Human Touch 1059 Eva Luo High-Value Palliative Care for Cancer Patients 1064 Ali John Zarrabi, Ran Huo, and Diane E. Meier History of Medicine Promoting Cost Transparency to Reduce Financial Harm to Patients 1073 Reshma Gupta, Cynthia Tsay, and Robert L. Fogerty Medicine and Society Countering Medicine’s Culture of More 1079 Hyung J. Cho Resources Suggested Readings and Resources 1082 About the Contributors 1098 1008 www.amajournalofethics.org American Medical Association Journal of Ethics November 2015, Volume 17, Number 11: 1009-1018 PEER-REVIEWED ARTICLE Why Can’t We Be Friends? A Case-Based Analysis of Ethical Issues with Social Media in Health Care Kayhan Parsi, JD, PhD, and Nanette Elster, JD, MPH “A George Divided Against Itself Cannot Stand!” [1] This quote comes from the ever-popular ’90s sitcom Seinfeld. In this classic scene, the always-put-upon George Costanza complains to his best friend Jerry about his two selves—Independent George and Relationship George. Independent George is the George that both George and Jerry love (bawdy, lying, etc.), whereas Relationship George is the identity that George maintains with his girlfriend, Susan. His concern is that if he does not create a firewall between these two identities, Relationship George will subsume Independent George. The exchange between George and Jerry humorously illustrates the real-life challenges of our brave new world of social media. Like George, who wants to maintain a boundary between his two personal (“bawdy” and relationship) identities, health care professionals are concerned about keeping their professional identities separate from their personal identities online [2]. The issue of boundaries is but one of many that the use of social media raises. In fact, the ubiquitous use of social media has created a number of potential ethical and legal challenges, some of which we will cover in this article. Specifically, we will: 1. Define social media; 2. highlight some recent instances of the good, bad, and ugly—social media used for good purposes, bad purposes, and plain ugly purposes; 3. outline salient professional and ethical issues; 4. review some illustrative case examples; and 5. highlight where to find recent policy recommendations. In many ways, social media is a liberating tool for millions of people throughout the world. The challenge for health care professionals is how to use social media in a responsible and thoughtful way. In this essay, we hope to foster a more reflective dialogue on both the benefits and potential risks of using social media in the health care context, particularly through a series of case vignettes. What is Social Media? A technical description of how social media works is as follows: social network sites…[are] web-based services that allow individuals to (1) construct a public or semi-public profile within a bounded system, (2) AMA Journal of Ethics, November 2015 1009 articulate a list of other users with whom they share a connection, and (3) view and traverse their list of connections and those made by others within the system. The nature and nomenclature of these connections may vary from site to site [3]. The term “social media” includes such personal and professional platforms as Facebook, Twitter, LinkedIn, Tumblr, and Pinterest, to name just a few. Although Facebook is still the social media juggernaut with more than a billion active users [4], new social media technologies appear on an almost daily basis. The existence of social media has not-so-quietly revolutionized the way human beings interact and connect with one another both personally and professionally. For thousands of years, geographic distance and lack of technologies for communication across that distance posed significant barriers to how people connected with one another. The invention of the Gutenberg printing press in the fifteenth century was the beginning of the revolution that made the printed word accessible. The second revolution was the creation in the nineteenth and twentieth centuries of mass communication technologies such as the telephone, radio, and television. The third revolution was the recent creation of social media outlets through which anyone with a smart phone can circulate a story or update to anyone else in the world. As of October 2014, 64 percent of US adults had a smartphone [5]. The Good, the Bad, and the Ugly Social media has the potential to truly improve health behaviors, allow governments to respond to public health emergencies, and even alert pharmaceutical companies to adverse drug reactions more rapidly than current reporting mechanisms (perhaps even in real time). It also allows those with rare diseases to have more expansive networks to learn about their condition and treatments and gain helpful psychosocial support. As one disease advocate put it, “the internet has made our small disease larger and we are able to educate many more people now” [6]. These groups can be a much-needed source of emotional support and information exchange. Unfortunately, irresponsible use of social media is fraught with hazards. There have been reports of patients stalking their physicians [7], health care professionals disclosing private information about patients [8], and students blogging denigrating descriptions of patients under their care [9]. A 2009 study published in JAMA revealed that 60 percent of medical schools surveyed “reported incidents of students posting unprofessional online content” [10]. The now-infamous Yoder case highlighted the hazards of students inappropriately blogging about their patients [9]. There have even been reports of medical residents losing their jobs for taking inappropriate photos, none perhaps more salaciously than the BBC News headline, “US ‘Penis Photo Doctor’ Loses Job” [11]. As one ethics commentator in the Journal of Clinical Ethics stated: “You can’t make this stuff up. 1010 www.amajournalofethics.org And unfortunately, you don’t have to” [12]. These behaviors are ethically problematic and could possibly trigger libel suits or other legal actions. Professional Ethical Issues The use of social media in the health care setting raises a number of professionalism issues including concerns related to privacy and confidentiality; professional boundaries; recruitment; the integrity, accountability, and trustworthiness of health care professionals; and the line between professional and personal identity [13]. Below we discuss the first issue, which is foundational to the others. Privacy and confidentiality are often used interchangeably but they have some crucial differences. Privacy is typically focused on the person—how and when an individual may share of him or herself. This is patient-controlled. Confidentiality, on the other hand, is focused on information that has been shared with someone else in a relationship of trust. This is controlled by the physician (or other health care professional). Maintaining privacy and confidentiality are integral to the patient-health care professional relationship, since preserving patient trust is essential for competent clinical care. Without some commitment to confidentiality, many patients would be disinclined to share intimate information about themselves or their health histories, which could compromise the delivery of health care. With the advent of the Health Insurance Portability and Accountability Act (HIPAA) enacted in 2003 [14], health care entities were legally allowed to disclose protected health information (PHI) only to facilitate “treatment, payment, and health care operations” [15]. In the remaining part of this essay, we consider several case studies (some taken from the news and some hypothetical) that highlight the more salient ethical and legal issues that arise with the proliferation of social media use in health care. Case Study One: The Global Health Student A medical student is on an immersion trip to the Dominican Republic during the summer after her first year. She wishes to document her experience with the patients she encounters by photographing them in the clinical setting. She speaks fluent Spanish and asks for verbal consent from a patient to take her picture before doing so. She does not tell the patient what she plans to do with it. She uploads the photo to her Facebook account, describing the patient’s clinical issues. What are some of the issues this case raises? Although legal norms governing privacy and confidentiality in the US and the Dominican Republic may differ, one could argue that ethical norms should not. The first question to ask is what does consent mean here? Is it a simple verbal consent that is not documented? Does the patient have a right to know the intended use of the photos and whether it is public or relatively private? Will the AMA Journal of Ethics, November 2015 1011 photos be used for educational purposes or will they simply be shared through a personal Facebook account? These are all important considerations to reflect upon before the student takes these photos during her immersion trip, and they highlight the necessity of distinguishing between personal use and professional use of social media. Opinion 5.045 of the American Medical Association (AMA) Code of Medical Ethics discusses filming patients in health care settings. Although it does not squarely address social media, one could look to it for some guidance. For instance, this opinion states that “filming patients without consent is a violation of the patient’s privacy.” By this logic, taking a photo of a patient and then uploading it to Facebook without consent is also a violation of the patient’s privacy. In a recent AMA Journal of Ethics article, Terry Kind cites the American College of Physicians and the Federation of State Medical Boards guidelines’ injunction to pause: “Trust yourself, but pause before posting to reflect on how best to protect and respect patients, their privacy, and your professional relationships and responsibilities” [16]. This student would do well to do likewise. Case Study Two: The Tweeting Physician A physician who works in a private practice is openly critical of health care reform. He tweets: "I don’t support Obamacare or Obama; patients who voted for him can seek care elsewhere.” His colleagues are concerned that his political views may hurt their practice; moreover, they wonder if it’s ethical for a physician to refuse to see someone because of his or her political views [17]. This scenario raises many concerns. First of all, we have a First Amendment-protected right to free speech. Various forms of social media have facilitated the ability of many more people to publicly exercise this right. And, indeed, this physician has a First Amendment right to express his political views. For instance, a physician may submit a letter to the editor of a newspaper, expressing his or her political views. Presumably such a letter would be vetted by an editor. Social media has no editor. Therefore, it’s even more incumbent upon a practicing physician to be careful about expressing political views online. The AMA Code of Medical Ethics allows physicians to discuss political matters directly with their patients unless “patients and their families are emotionally pressured by significant medical circumstances” [18], but “communications by telephone or other modalities with patients and their families about political matters must be conducted with the utmost sensitivity to patients’ vulnerability and desire for privacy.” Current patients of this physician may find his behavior contrary to sensitivity to their vulnerabilities. And the physician’s own colleagues may view such behavior as inappropriate or even contrary to whatever contractual terms the physician signed. Furthermore, the AMA Code also proscribes discriminating against patients because of their “race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination” [19]. Is it permissible, then, for a physician to refuse to care for someone because of his or her political views? 1012 www.amajournalofethics.org Case Study Three: The Googling Program Director A residency program director is overwhelmed with resident applications. He has started to search applicants on Google to learn about their online identities. He discovers that a few of the students applying to his program have photos in their Facebook profiles that show them in an unflattering light. One is holding a drink at a party, appearing to be inebriated. Most disturbing is one set of photos in which the students (and even some physicians) are brandishing weapons on what appears to be an international immersion trip [20]. Human resources departments and hiring committees are increasingly turning to the Internet to learn more about applicants’ online activities. They may acquire certain personal information via social media outlets such as Twitter or Facebook or they may even learn about an applicant’s professional disciplinary history. Indeed, employers routinely retain services to check an applicant’s criminal background. They also follow up with references supplied by applicants. This scenario raises questions about conducting such searches through the use of social media: Are such searches ethically permissible? How reliable is the information found? Do job applicants have any expectations of privacy? It may be incumbent upon an employer to screen applicants by doing a simple Google search to ensure that nothing troubling is uncovered, but the reliability of the information remains questionable, and it may be that such information should not be used in decision making without first allowing the applicant the opportunity to provide an explanation. Perhaps, then, prospective applicants should be notified that such searches will be conducted. We must all remember that no consent is required for someone to post photos of another person on Facebook, so, even if an applicant is not a Facebook user, others still may post identifying information and photos that are not all that flattering. Case Study Four: Connecting on LinkedIn A young pediatrician has recently finished his training and is now a newly minted attending physician. He is building his practice and has active accounts with Facebook and LinkedIn. A mother of one of his patients has recently sent a request to be his “friend” on Facebook. He declines this friend request, believing that this may impair his clinical judgment. He wonders, however, if it would be appropriate to connect with this patient’s mother through LinkedIn, since it is a site for professional networking as opposed to personal friendships. As the opening anecdote about George Costanza suggests, the boundaries between our professional and personal lives have become increasingly blurred. Nonetheless, many people will attempt to construct some kind of boundaries with various forms of social media. For instance, many think of LinkedIn as strictly a professional networking site and would never post personal information there. The pediatrician in this scenario may think that connecting with a patient’s mother on LinkedIn is purely a professional connection. A challenge arises, however, if the mother of the child reaches out to the pediatrician AMA Journal of Ethics, November 2015 1013 through LinkedIn with a question about her child’s health. Is the pediatrician obligated to respond? If he does not, is he potentially liable? Are privacy issues raised if various patients are connecting with the physician through social media and all become aware of one another’s identity and that they are, in fact, patients? Although they are voluntarily connecting with their physician, it may not be transparent to users that they may be connected to that physician’s other patients. Case Study Five: Patient Targeted Googling [21] A physician treating an elderly woman for shortness of breath began looking for the cause of her worsening condition. He sent for a drug screen, on which she tested positive for cocaine. She told him she had no idea how cocaine could be in her system, which made him concerned she might be a victim of abuse. One of the nurses involved in her care Googled her and discovered that she had a previous police record for cocaine possession [22]. This kind of activity has garnered increasing attention, especially among psychiatrists and other practitioners in mental health. The situation is not unlike the residency program director Googling applicants—information on the Internet is freely available. Why shouldn’t a responsible health care practitioner Google a patient to learn more potentially helpful information about him or her? The issue here is one of trust. Currently, patients expect that what they share with a physician is the sum total of the doctor’s information about them. It has been argued that such online research about patients should be avoided, unless there is a significant health or safety issue at stake [23]. Guidelines for the Responsible Use of Social Media In response to the proliferation of social media use among health professionals and students in training, various educational institutions and professional organizations have developed guidelines. For instance, Loyola University Chicago Stritch School of Medicine [24], Northwestern University Feinberg School of Medicine [25], and the Mayo Clinic [26] have all responded with formal policies on the use of social media by students, faculty, and staff. In addition, both the American Medical Association [27] and the British Medical Association [28] have developed formal guidelines on the use of social media in health care. Lastly, the Federation of State Medical Boards has developed “Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice” [29]. Although ethics and law often lag behind technological innovation, we now have a burgeoning set of policies to help health care professionals more thoughtfully use social media in their work and in their private lives. These new policies address a number of issues raised by the cases discussed here: privacy, boundaries, professional identity, and one’s reputation. We highly recommend that such policies be promoted and that institutions seriously consider developing their own internal policies. 1014 www.amajournalofethics.org Various forms of social media have transformed the way human beings interact with one another. Anyone with Internet access or a smartphone can now transmit tweets, Facebook postings, and Instagram images to hundreds, even thousands, of other people, all of whom can share this same information with their own network of contacts. This kind of technology can be liberating, but it also can create potential ethical and legal challenges for health care professionals. To address some of these challenges while availing our profession of some of the benefits, we recommend the following: • Have a clear understanding of local, state, and national laws concerning privacy. • Have a working knowledge of professional society guidelines. • Know your institutional culture. • Be prepared to make changes to stay current with the rapid developments in technology. • Circulate policies, including updates, in writing to all who are required to abide by them. • Differentiate between guidelines for education and guidelines for practice, if appropriate. • Educate all (students, staff, faculty) about the policies. Because all forms of social media have become so integrated into the social fabric, managing social media use on both a personal and professional level has become imperative. As Greysen et al. have concluded in an article in the Journal of General Internal Medicine: Certainly, the principle of “first, do no harm” should apply to physicians’ use of social media, but we can do better. Just as we must look beyond harm reduction towards health promotion in clinical practice, we must go farther than curtailing unprofessional behavior online and embrace the positive potential for social media: physicians and health care organizations can and should utilize the power of social media to facilitate interactions with patients and the public that increase their confidence in the medical profession. If we fail to engage this technology constructively, we will lose an important opportunity to expand the application of medical professionalism within contemporary society. Moreover, a proactive approach on the part of physicians may strengthen our patients’ understanding of medical professionalism [30]. 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