Ethical Considerations in Pediatricians' Use of Social Media - OHSU

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CLINICAL REPORT             Guidance for the Clinician in Rendering Pediatric Care

                           Ethical Considerations in Pediatricians’
                           Use of Social Media
                           Robert Macauley, MD, FAAP,a Nanette Elster, JD, MPH,b Jonathan M. Fanaroff, MD, JD, FAAP,c COMMITTEE ON BIOETHICS,
                           COMMITTEE ON MEDICAL LIABILITY AND RISK MANAGEMENT

Increasing use of social media by patients and clinicians creates opportunities            abstract
as well as dilemmas for pediatricians, who must recognize the inherent
ethical and legal complexity of these communication platforms and maintain
                                                                                           a
                                                                                            Department of Pediatrics, Oregon Health and Science University,
professionalism in all contexts. Social media can be a useful tool in the                  Portland, Oregon; bNeiswanger Institute for Bioethics, Stritch School of
practice of medicine by educating both physicians and patients, expanding                  Medicine, Loyola University Chicago, Chicago, Illinois; and cDepartment
access to health care, identifying high-risk behaviors, contributing to research,          of Pediatrics, School of Medicine, Case Western Reserve University and
                                                                                           Rainbow Center for Pediatric Ethics and Division of Neonatology,
promoting networking and online support, enhancing advocacy, and nurturing                 University Hospitals Rainbow Babies and Children’s Hospital, Cleveland,
professional compassion. At the same time, there are confidentiality, privacy,              Ohio

professionalism, and boundary issues that need to be considered whenever                   Clinical reports from the American Academy of Pediatrics benefit from
potential interactions occur between physicians and patients via social media.             expertise and resources of liaisons and internal (AAP) and external
                                                                                           reviewers. However, clinical reports from the American Academy of
This clinical report is designed to assist pediatricians in identifying and                Pediatrics may not reflect the views of the liaisons or the
                                                                                           organizations or government agencies that they represent.
navigating ethical issues to harness the opportunities and avoid the pitfalls of
social media.                                                                              Drs Macauley and Elster drafted the article; and all authors
                                                                                           participated in conception and design of the report, data collection,
                                                                                           analysis, and interpretation, and critical revision of the article and
                                                                                           approved the final manuscript as submitted.

                                                                                           The guidance in this report does not indicate an exclusive course of
INTRODUCTION                                                                               treatment or serve as a standard of medical care. Variations, taking
                                                                                           into account individual circumstances, may be appropriate.
Increasing use of social media by patients and clinicians creates
                                                                                           All clinical reports from the American Academy of Pediatrics
opportunities as well as dilemmas for pediatricians, who must recognize                    automatically expire 5 years after publication unless reaffirmed,
the inherent ethical and legal complexity of these communication                           revised, or retired at or before that time.

platforms and maintain professionalism in all contexts. This clinical report               This document is copyrighted and is property of the American
                                                                                           Academy of Pediatrics and its Board of Directors. All authors have filed
is designed to assist pediatricians in identifying and navigating ethical                  conflict of interest statements with the American Academy of
issues to harness the opportunities and avoid the pitfalls of social media.                Pediatrics. Any conflicts have been resolved through a process
As Parikh et al1 rightly observe, “Connectivity need not come at the price                 approved by the Board of Directors. The American Academy of
                                                                                           Pediatrics has neither solicited nor accepted any commercial
of professionalism.” In fact, striking a proper balance may be considered                  involvement in the development of the content of this publication.
an ethical imperative, with the goal that social media (to the extent that it              DOI: https://doi.org/10.1542/peds.2020-049685
is used) augment in-person care rather than take the place of it.
                                                                                           Address correspondence to Robert Macauley, MD. E-mail: macauler@
More than 300 million people in the United States now use the Internet,2                   ohsu.edu

with more than 90% of them also using e-mail to communicate.3 With the
creation of social media outlets (also known as Web 2.0) at the dawn of                        To cite: Macauley R, Elster N, Fanaroff JM, AAP COMMITTEE
the 21st century, the capacity for sharing information among huge                              ON BIOETHICS, COMMITTEE ON MEDICAL LIABILITY AND RISK
numbers of people with little or no time lag reached new heights. “Social                      MANAGEMENT. Ethical Considerations in Pediatricians’ Use
                                                                                               of Social Media. Pediatrics. 2021;147(3):e2020049685
media” refer to Web-based services that allow users to create personal

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PEDIATRICS Volume 147, number 3, March 2021:e2020049685                                FROM THE AMERICAN ACADEMY                           OF PEDIATRICS
profiles and post content4 as well as         and “digital immigrants” (defined as             maintains a list of more than 700
“articulate a list of other users with       people born before 1980) and, thus,             tweeting AAP members, known as
whom they share a connection.”5              have varying understanding and                  “Tweetiatricians.”17
E-mail and other forms of electronic         facility with social media.13 This
                                                                                             Overall, 90% of physicians today use
communication specifically designed           relative unfamiliarity, coupled with
                                                                                             social media for professional
to be used between a single user and         reports of violations of online
                                                                                             purposes, including finding and
another, such as electronic patient          professionalism (which more than
                                                                                             reading relevant medical
portals, are not considered social           90% of state medical boards have
                                                                                             information.18 Social media are
media6 and are not the focus of this         received, leading to sanctions ranging
                                                                                             especially popular with early-career
report. Seventy-two percent of               from suspension to revocation of the
                                                                                             pediatricians who may be more
Americans, including 90% of                  physician’s license15), may cause
                                                                                             familiar with digital technology, have
teenagers, engage in social media,7–9        some pediatricians to be reluctant to
                                                                                             received mentoring in its use during
with Facebook among the best known           engage with social media.
                                                                                             training, or attend conferences in
and most frequently used by adults.
                                             Avoiding social media, however,                 which tweeting is encouraged to ask
Others include Instagram, Twitter,
                                             sacrifices opportunities for                     questions or provide feedback. Social
LinkedIn, Tumblr, Snapchat, and
                                             communication, education, and                   media allow learners to express their
Pinterest. Newer social media options
                                             advocacy with patients and families.            opinions and ask questions without
are being created regularly as public
                                             As Parsi and Elster16 note, “If we fail         fear of embarrassment and has been
needs and demands shift.10 Social
                                             to engage this technology                       observed to “flatten the hierarchy” of
channels are evolving and changing
                                             constructively, we will lose an                 medicine by giving each person an
with time, allowing for instant and
                                             important opportunity to expand the             equal voice.19
disappearing messages, back-channel
                                             application of medical
connections, live video streaming, and                                                       Patient Education and Advocacy
                                             professionalism within contemporary
one-to-many communications. Some
                                             society.” Both the potential benefits            Studies have revealed that 8 in 10
social channels have been specifically
                                             and risks of social media need to be            Internet users go online for health
designed for physician
                                             considered to appropriately                     information,20 and more than half of
communication, either with peers,
                                             incorporate it into one’s clinical              these people get medical information
patients, or the public.
                                             practice.                                       specifically from social media.21
Because of social media’s ubiquity                                                           Social media tools can be used to
and ease of use, a high percentage of                                                        share relevant and important public
patients want or expect to use it to         POTENTIAL BENEFITS OF SOCIAL MEDIA
                                                                                             health topics and to guide the public,
communicate with their physician. In         Professional Education and                      patients, and families who follow
a recent Harris Poll survey conducted        Collaboration                                   a physician’s channels to creditable
on behalf of the American                                                                    resources that have been reviewed by
                                             Faced with multiple competing
Osteopathic Association, it was found                                                        physicians (such as online media
                                             obligations and rigorous productivity
that “more than half of millennials                                                          articles, blogs, journal articles, or
                                             expectations, physicians may need to
(54%) and more than four out of 10                                                           important recall or safety
                                             consult with colleagues about
(42%) adults are or would like to be                                                         information). Communication may
                                             challenging cases or research current
friends with or follow their health                                                          range from general advice, such as
                                             evidence quickly. Social networking
care providers on social media.”11                                                           encouragement to get the seasonal
                                             sites can help close this gap, as long
Research reveals that patients who do                                                        influenza immunization, to broad-
                                             as they are compliant with privacy
not currently use social media would                                                         ranging notifications about public
                                             requirements of the Health Insurance
consider doing so to improve                                                                 health emergencies.
                                             Portability and Accountability Act
physician-patient communication.12
                                             (HIPAA) (which would include                    Beyond mere ease and scope,
This is particularly true of pediatric
                                             identity verification and sufficient              education via social media may be
patients, who as “digital natives” (ie,
                                             encryption). Physician-to-physician             preferable for patients who have
people born or raised in the age of
                                             communication can also occur on                 moved beyond the model of acquiring
digital technology13) are more
                                             public channels such as Twitter,                knowledge from a medical
familiar with communicating with
                                             through which groups of physicians              professional in the clinical workspace.
and expressing themselves through
                                             congregate and “follow” each other              Some patients prefer
social media than are many adults.14
                                             for information sharing, thought                “disintermediation,” or gathering
Pediatricians, however, are,                 leadership, and advocacy in pediatric           information directly from online
depending on their generation and            public health. The American Academy             sources. Recognizing that not every
experience, a blend of digital natives       of Pediatrics (AAP), for example,               such source is trustworthy, physicians

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2                                                                                                 FROM THE AMERICAN ACADEMY OF PEDIATRICS
can encourage a middle ground. The               community health needs. For                      Increased Patient Access
so-called “apomediary model” allows              instance, appeals for voluntary blood            In regions with inadequate
physicians to guide patients to                  donation on social media can help to             infrastructure to support optimal
reliable information that they can               mitigate acute shortages. Organ                  telemedicine, social media sites, such
access independently before turning              donation recruitment has also                    as Facebook, have been used
to their physician for consultation              increased in response to Facebook                instead.37 Ideally, social media should
and clarification.22                              appeals.27                                       not replace face-to-face encounters
Social media can also be used to                                                                  with physicians, but social media may
implement advocacy initiatives to                Patient Empowerment                              supplement those encounters by
enhance public health. Examples                                                                   creating virtual clinics, thus allowing
                                                 Social media have made the world                 a more rapid response to an urgent
include appeals to contact elected
                                                 smaller and have provided a global               health care situation.
officials to advocate for policies and
                                                 community to support patients with
legislation that improve the health of
                                                 special needs and chronic health                 Clinical Research and Recruitment
children and their families and the
                                                 conditions as well as individuals who
promotion of public and community                                                                 Social media can expand research
                                                 may be experiencing social isolation
health via immunization campaigns.                                                                opportunities and connect
                                                 or discrimination. Peer-to-peer health
Recent polls suggest that fully two-                                                              researchers to peers, novel ideas, and
                                                 care affords patients the
thirds of Americans believe that                                                                  potential human subjects or study
                                                 opportunities to develop a support
social media are important for getting                                                            participants. Social media tools are
                                                 network, share experiences, and learn
elected officials to pay attention to                                                              not only used to broadcast ideas; they
                                                 about new opportunities for research
issues and that social media                                                                      can also be used to search for
                                                 or treatment.28 Many private
platforms are “at least somewhat                                                                  information, opinions, and ideas or
                                                 companies,29,30 including some
important for creating sustained                                                                  simply to listen. Such tools allow
                                                 focused on pediatrics,31 have such
movements for social change.”23                                                                   researchers to contact patients with
                                                 online communities for patients to
                                                                                                  rare conditions and locate research
These social media opportunities are             connect with each other and work to
                                                                                                  subjects lost to follow-up as well as
widely accessible to, and can be used            systematically improve their health
                                                                                                  reach out to younger patients who
to influence, public opinion, as recent           outcomes. Facebook32 and Twitter33
                                                                                                  might otherwise not learn about or
interference in US elections attests.24          have both allowed the creation of
                                                                                                  become interested in participating in
Opponents of certain medical                     “supportive disease subcultures.” As
                                                                                                  research.38 Social media can inform
recommendations or public policies               one patient noted, “The internet has
                                                                                                  researchers about patient responses
can provide conflicting or inaccurate             made our small disease larger and we
                                                                                                  to treatment and adverse drug effects
information that may trigger                     are able to educate many more people
                                                                                                  and trigger modifications in
discussions and debate.25 Although               now.”34
                                                                                                  treatment plans.39
currently only 9% of physicians use
social media to comment on posts or              In addition to fostering community               Use of social media in research is
participate in group discussions or              and providing education, social                  ethically complex, however. Whereas
online chats,18 physicians                       media also hold the promise of                   most research studies are developed
participating in social media may help           improved diagnostics. Patients (and              by experienced researchers and
prevent misconceptions from                      their advocates) can now share                   approved by their organization’s
dominating online discussions.                   reports online of unusual symptom                institutional review board or human
                                                 complexes that have stumped local                subjects committee, studies involving
Social media can help patients and
                                                 physicians. These disclosures may                social media may bypass this review
families understand the range of
                                                 be similar to diagnostic dilemmas                process because social media use is
expertise of a given practice and learn
                                                 among other patients and provide                 seen as public, thus calling into
of additional resources in their
                                                 physicians with diagnostic clues.26              question whether it is necessary to
community. In some cases, with
                                                 Identifying groups of patients                   obtain the participants’ informed
patient authorization, social media
                                                 with a common condition can also                 consent.40 Protection of human
can permit the transmission of
                                                 spur further research on that                    subjects is critical, however, and
personalized information (such as
                                                 disease’s pathophysiology and                    researchers who use social media in
appointment or medication refill
                                                 treatment. 35,36 This process has                their studies should continue to
reminders), which can help improve
                                                 been likened to crowdsourcing, or                follow the policies of their
adherence to treatment regimens.26
                                                 bringing together the collective                 institution’s ethics committee or
Social media can also benefit patients            wisdom of diverse groups of                      institutional review board.
by increasing awareness of                       patients and physicians.22                       Investigators should disclose that

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PEDIATRICS Volume 147, number 3, March 2021                                                                                             3
a research study is being considered,       indiscriminate queries (sometimes               addresses, or other traditionally
be clear about the risks and benefits        referred to as “patient-targeted                verifiable information is not
of the research, and, if possible,          googling”) present significant ethical           a guarantee that one’s identity will
obtain consent from potential study         complexity and concerns, which will             remain anonymous.
subjects before proceeding with the         be addressed below.
study rather than merely lurking to
obtain data.38 Without such                 Nurturing Compassion Through                    POTENTIAL RISKS OF SOCIAL MEDIA
transparency, potential subjects            Narrative
                                                                                            Inappropriate Self-Disclosure
might post personal items on social         Medical practice today can be
media that they would have kept             challenging and exhausting. Sharing             Despite the potential benefits of
private if they had been aware of the       inspirational anonymized patient                social media, significant risks remain.
research taking place (from                 stories can nurture compassion                  One important risk is inappropriate
a practical viewpoint, there should be      among health professionals,                     personal self-disclosure by physicians
no expectation of privacy for               reminding them about why they                   online, which can negatively impact
information voluntarily posted              chose the profession in the first                a physician-patient relationship or
online41).                                  place.47 Humor has also been shown              one’s employment. Even if an
                                            to prevent burnout,48 and so-called             inappropriate posting on social media
Identification of and Counseling for         “collective venting” can be cathartic.49        is entirely unrelated to one’s medical
High-risk Behaviors                                                                         practice, it nevertheless reflects on
                                            By the same token, because social               one’s professionalism.55 As the
As digital natives, most pediatric
                                            media are publicly accessible,                  American Medical Association Code of
patients expect to communicate
                                            insufficiently anonymized patient                Ethics states, “The ethical obligations
through social media. Adolescents, in
                                            narratives (and even sufficiently                of physicians are not suspended when
particular, spend a great deal of time
                                            anonymized ones that are written in             a physician assumes a position that
online42 and may feel more at ease
                                            a negative venting tone) may reflect             does not directly involve patient
sharing personal information in that
                                            negatively on the authoring physician.          care.”56 This includes online
context rather than in face-to-face
                                            Even deidentified patient information            disclosures, and all professionals, not
conversation. Teenagers may also be
                                            holds the potential to be hurtful, both         just physicians, are judged by how
more open to health-related messages
                                            to that specific patient and to other            they comport themselves online.57
and advice communicated through
                                            patients who might fear that their
social media.43 Social media can,
                                            private information could be shared             By its very nature, social media invite
therefore, be used to identify self-
                                            in a similar manner. Denigrating                inappropriate posting because
disclosed high-risk behaviors and
                                            language is inherently personal and             “anonymity can breed
explore ways of mitigating risk and
                                            reflects poorly on the physician and             disinhibition.”58 Some posts are
accessing appropriate resources.44,45
                                            the profession of medicine itself.50            clearly inappropriate, such as selfies
Such conversations are more
                                            There is evidence that sharing                  of grinning clinicians posing with
straightforward when the pediatric
                                            dehumanizing narratives and                     weapons during a humanitarian
patient has specifically granted the
                                            language begins early in medical                mission59 or uncivil microblog posts
physician access to material posted
                                            training, with medical students                 (eg, tweets).60 Some posts may be
on social media, although such
                                            shown to frequently express                     more ambiguous but in the absence of
communication itself raises issues
                                            themselves in this way online.51 A              nonverbal cues can easily be
related to blurring of appropriate
                                            majority of medical schools now                 misinterpreted. Comments
boundaries (as discussed below).
                                            report unprofessional online                    addressing patients, as well as those
Greater discretion is required
                                            conduct.48 For precisely this reason,           regarding one’s employer or clinical
regarding social media information
                                            schools are starting to put forth               setting, reflect negatively on both the
that is in the public domain.
                                            policies regarding social media                 subject, the poster, and the
Acquisition of Important Information        expression.52                                   professional, potentially leading to
                                                                                            disciplinary action or even
In rare cases, social media have been       Even when details are deidentified               termination. Tweeting or posting
used to obtain specific and important        and a patient narrative is expressed            from work, especially if excessive,
information relevant to patient care.       in respectful terms, a majority of              may be perceived as not paying
For instance, the authors of one case       medical educators still believe that            attention to clinical duties and may
study describe how a Facebook               discussing it on social media requires          violate institutional policy.61
search allowed a medical team to            explicit patient consent.53,54 Given the
locate the family of a patient with         abundance of readily accessible                 There are permanent implications to
amnesia.46 Taken too far, however,          information, nondisclosure of names,            such disclosure, too, because despite

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4                                                                                                FROM THE AMERICAN ACADEMY OF PEDIATRICS
subsequent attempts to purge one’s               belief that the law requires [them] to           patient’s self-report, should the
online profile, what goes online stays            do so.”66                                        physician raise this issue with the
online. Unflattering social media                                                                  patient directly? How might that
                                                 Simply having a presence on
content may affect a clinician’s future                                                           discussion impact the patient’s
                                                 Facebook could permit a process
employment opportunities.62 Despite                                                               perception of privacy? Accepting
                                                 called tagging. Tagging involves
this risk, one study revealed that only                                                           a friend request may also raise
                                                 a facial recognition algorithm that
one-third of medical students set                                                                 expectations of off-duty availability or
                                                 identifies an individual from
their Facebook pages to private.63                                                                that clinical questions will be
                                                 photographs posted online. An
This may be significant given that                                                                 answered via less secure
                                                 unprofessional pose from a friend’s
some institutions may consider social                                                             social media.
                                                 party could end up appearing on
media and the content of postings in
                                                 one’s own Facebook feed. To prevent              Recognizing this ethical challenge,
promotion and tenure.64                          being tagged, Facebook settings can              75% of physicians decline friend
                                                 be modified.                                      requests from patients18 and only 5%
From a specifically pediatric
                                                 Unfortunately, tagging may also occur            have ever initiated one.7 More than
perspective, poor digital citizenship
                                                 from many social media platforms                 80% of medical educators believe
undermines a pediatrician’s
                                                 through comments and tweets. Even                that it is never or rarely acceptable to
important duty to serve as a role
                                                 if a pediatrician were to elect not to           become social networking friends
model for patients and families using
                                                 have a social media presence at all,             with patients.53,54 The American
social media. The AAP has previously
                                                                                                  College of Physicians,69 American
encouraged pediatricians “to increase            others are able to post information
                                                 and photographs about the physician,             Medical Association,26 British Medical
their knowledge of digital technology
                                                 including videos recorded and                    Association,70 and Federation of State
so that they can have a more
                                                 photographs taken without the                    Medical Boards15 all discourage
educated frame of reference for the
                                                 physician’s knowledge or consent. For            accepting (and certainly initiating)
tools their patients and families are
                                                 this reason, routinely monitoring and            friend requests with current or
using, which will aid in providing
                                                 curating one’s online presence is                former patients, although the recent
timely anticipatory media guidance as
                                                 recommended. Pediatricians can get               American College of Obstetrics and
well as diagnosing media-related
                                                 a sense of their online “footprint,” as          Gynecology statement permits some
issues should they arise.”42
                                                 well as their online “fingerprint”                measure of discretion in this area.71
To prevent inappropriate disclosure,             generated by their online work and               Additionally, some employers
it is best to pause before posting by            advocacy, by regularly searching their           prohibit friending patients.
taking a moment to reflect on the                 online presence.                                 This question becomes more
potential impact of a post should it be                                                           complex in a pediatric context given
seen by one’s colleagues, patients, or           Blurring Relationship Boundaries                 the reliance of pediatric patients on
families. It is in a physician’s best            As stated above, a recent poll found             social media as a forum for
interest to consider separating their            that most millennials and nearly half            expression and communication. It is
personal and professional social                 of adults want to follow or connect              generally inadvisable for
media presence and efforts. The                  with a health care provider on social            pediatricians to accept friend
professional platforms can have                  media.11 In one study, nearly 20% of             requests from current patients (and
public settings and content for                  adult patients attempted to                      certainly to initiate them). However,
education and advocacy, and the                  communicate with their physician                 declining a friend request might
personal platforms can be set to                 through Facebook.67 Accepting this               seem like it could compromise
private. Restricting access to one’s             type of relationship can be                      communication or even give offense
private social media accounts may be             problematic, however. “Friending”                to the requestor. If so, the physician
beneficial in light of reports of a few           blurs the boundaries of the                      should meet face to face and talk
patients using social media to stalk             professional relationship, not only              with the requestor and discuss with
their physicians.65 It is also wise to           heightening the possibility of                   them why a dual relationship is not
remember that online postings are                inappropriate physician self-                    wise or in the patient’s best interest.
discoverable in legal proceedings.               disclosure68 but also introducing                An alternative way to maintain
Facebook’s privacy policy clearly                a level of mutuality that can                    communication would be to redirect
states that they may “access, preserve           undermine a patient’s privacy and                the requestor to the pediatrician’s
and share your information…in                    patient-physician interactions. For              professional site or a separate
response to a legal request (like                example, if a physician discovers                platform on which no other
a search warrant, court order, or                something on a patient’s Facebook                personal or professional posts
subpoena) if [they] have a good faith            page that is not consistent with the             are made.

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PEDIATRICS Volume 147, number 3, March 2021                                                                                              5
Unlike in other specialties, pediatric       This does not require an in-person              online profiles and biographies
patients “age out” of the therapeutic        meeting and could conceivably occur             whenever possible.
relationship with their physicians.          online. Although specific
Social media present a way for               requirements vary from state to state,          Confidentiality
pediatricians to stay in contact with        it is likely that, regarding social
                                                                                             The Hippocratic Oath states, “I will
former patients. When not doing so is        media, the broadest notion of what
                                                                                             respect the privacy of my patients, for
felt to represent a significant mutual        constitutes a physician-patient
                                                                                             their problems are not disclosed to
loss, it is up to the pediatrician’s         relationship could be adopted.71
                                                                                             me that the world may know.” The
discretion whether to remain in touch        Clinical questions posed through
                                                                                             HIPAA Privacy Rule, which covers
with former patients via social media.       social media could, therefore,
                                                                                             “individually identifiable health
                                             potentially create a professional
Becoming social media friends with                                                           information” based on 18 possible
                                             obligation with documentation and
the parent of one’s patient is also not                                                      identifiers, including “full-face
                                             follow-up requirements similar to
without ethical complexity given that                                                        photographic images (and any
                                             those of an office visit as well as
that the parent is usually tasked with                                                       comparable images),”76 also applies
                                             a potential liability risk, which may
making decisions for the patient and                                                         to social media, as do state privacy
                                             not be covered by malpractice
may be unduly influenced in the                                                               laws.50 Physicians have an ethical and
                                             insurance. What began as a kind-
decision-making by the friend                                                                legal obligation to keep protected
                                             spirited attempt to offer general
relationship. Such friending may also                                                        health information confidential.
                                             assistance could ultimately result in
create an avenue of communication                                                            Despite this duty, there have been
                                             medicolegal obligations (and
that could lead to an unintended                                                             reports of physicians sharing details
                                             liability), underscoring the need for
disclosure of identifiable health                                                             about patients or inadequately
                                             physicians to be extremely cautious
information to the patient and family.                                                       deidentifying facts and
                                             about health care communications
Ethical issues in this friendship may                                                        photographs77,78 because even
                                             with personal friends and about
become even more complicated if the                                                          blocked-out faces in photographs may
                                             posting anything that could be
social media relationship continues                                                          still be identifiable. Social media
                                             construed as representing a diagnosis
once the pediatric patient reaches the                                                       postings that reference a medical
                                             or treatment.
age of majority and the parent is no                                                         encounter with a specific time and
longer responsible for making                Conflict of Interest                             date could be seen by patients and
decisions for the patient. It is,                                                            damage trust in the physician-patient
                                             As noted above, social media provides
therefore, problematic to engage in                                                          relationship and likely violate HIPAA.
                                             valuable opportunities for health
social media contact with parents of         advocacy and patient education but              To facilitate appropriate use of such
patients if social media are the only        can also raise the possibility of               digital communication, several legal
basis of the relationship.                   conflict of interest. For example, 11%           issues need to be addressed. These
In some instances, however (such as          of physician-written health care blogs          include licensure across state lines or
small communities or areas in which          include named products.73 Tweets                international borders,79 adequate
the physician and the parent have            may involve “suspect promotions.”74             malpractice insurance coverage,
other mutual interests), such contact        Because using social media is                   reimbursement for telecare (if
can be a normal expression of                relatively easy, many more clinicians           available), and maintaining
friendship. Once again, it is                may be tempted to consider a paid               confidentiality (because HIPAA also
imperative to maintain proper                promotion without understanding the             applies to social media
boundaries by reserving clinical             ethical and legal implications of such          communications). When a physician
discussions for separate forums.             conflicts of interest if promulgated             is communicating about health care
                                             without appropriate disclosure. Such            or rendering advice directly to
Up to this point the discussion has          arrangements have also occurred in              patients or families, HIPAA
been focused on established patients         traditional media and violate                   compliance requires the use of
attempting to become friends on              journalistic and educational ethics             a secure site with encryption.
Facebook, but the reverse process (ie,       (not to mention Federal Trade                   Removing any identifiable patient
friends on Facebook becoming                 Commission regulations75) if not                details preserves the patient’s
patients) has also occurred. Generally       publicly disclosed. Even an individual          anonymity and underscores the
speaking, a physician-patient                message on Twitter (a tweet) allows             practice’s compliance with state and
relationship consists of a patient           pediatricians to include a conflict of           federal law. The option of 24/7
seeking assistance in a health-related       interest statement despite the 280-             patient communication also demands
matter and the physician agreeing to         character limit. Employment                     appropriate attention to the
undertake diagnosis and treatment.72         relationships should be revealed in             physician’s own work-life balance.

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6                                                                                                 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Impact on Professional Reputation                in such reporting, which include                 information gathered from social media
A significant number of patients use              having to determine what content                 sources.54 For example, if an adolescent
online rating sites to choose their              crosses the line and not wanting                 patient denies drinking alcohol but has
physician. Given the impact of one’s             a colleague to get in trouble, may               posted on social media about drinking
online presence on professional                  explain why few other codes include              to excess, should the pediatrician
reputation, it is advisable for                  this requirement, although it is                 confront the patient with this newfound
physicians to monitor the status of              frequently included in social media              information? To do so might
their online identity.80 Although most           guidelines written by hospitals,                 compromise trust, but not doing so
physician ratings are positive,71,81,82          academic centers, and other health               might preclude thoughtful intervention.
there have been reports of ratings               care employers.
                                                                                                  The other type of information patient-
sabotage (ie, fabricated negative                Given these concerns, pediatric                  targeted googling may generate
reviews) by competing professionals              practices and other health care                  comes from third-party sources,
or disgruntled patients.81 Given the             organizations may wish to                        ranging from news articles to posts
anonymity of many reviews, such                  formulate social media policies for              from someone other than the patient.
a situation may be difficult to                   their employees, which can clarify               Such non–user-generated Internet
remedy.83                                        expectations, provide valuable tools             content presents a different set of
                                                 and information, and ultimately                  challenges. First, there is no
Responding thoughtfully and
                                                 protect patient confidentiality                   guarantee that the information is
positively to critical reviews can be
                                                 and privacy. These policies may                  accurate. Even if it is, acquiring
helpful. Physicians must remember
                                                 also include expectations and                    knowledge about a patient that the
that patients can post whatever they
                                                 standards for communicating with                 patient did not directly provide (and
want about a situation, but the
                                                 patients through social media,                   may not be aware that the physician
physician remains bound by
                                                 such as response time and                        is in possession of) threatens to
confidentiality obligations. Responses
                                                 documentation.84                                 compromise trust. Uncertainty
must always be generalized, not
specific to an individual. It is                  Inappropriate Acquisition of                     remains as to whether to reveal one’s
important to recall that HIPAA                   Information via Social Media                     knowledge of this information to the
regulations prevent physicians from                                                               patient, either to confirm its veracity
                                                 As noted above, there may be
disclosing any protected health                                                                   or engage in discussion about its
                                                 instances in which social media can
information about the patient,                                                                    content.
                                                 be used to obtain specific and
including acknowledging that the                 relevant information about patients              Before pediatricians engage in
person is or was a physician’s patient.          (such as the example of locating the             patient-targeted googling, it is
Unfair or potentially fabricated                 family of a patient with amnesia                 important to identify the information
reviews can be reported to the rating            through Facebook). This practice has             they are seeking to acquire and
Web site or, depending on one’s work             become increasingly common. In one               determine if it is of sufficient
context, to the public relations                 study, 1 of 6 pediatric trainees had             importance to justify such a search.
division of one’s employer. Another              conducted Internet or social media               Clinton et al87 suggest 6 questions to
solution can be to optimize search               searches for more information about              consider before engaging in patient-
engine results so that one’s own                 a patient, and a similar percentage of           targeted googling:
practice site comes up first, before              faculty believed they would do so if
                                                                                                  • “Why do I want to conduct this
any potentially negative reviews.                that might help in patient care.85
                                                                                                    search?”
Encouraging more patients to review              This practice could, however, expand             • “Would my search advance or
the practice online will likely provide          to indiscriminate searches for                     compromise the treatment?”
a balanced and generally                         information about patients.86 So-called
positive view.                                   patient-targeted googling can be                 • “Should I obtain informed consent
                                                 motivated by a genuine desire to                   from the patient prior to
The American Medical Association                                                                    searching?”
Code of Ethics not only mandates                 understand more about one’s patients
                                                 and perhaps gauge their adherence to             • “Should I share the results of the
ethical behavior on the part of
                                                 treatment plans. But it can also stem              search with the patient?”
physicians but also requires
physicians to report unprofessional              from “curiosity, voyeurism, and habit.”15        • “Should I document the findings of
behavior on the part of their peers.56           Patient-targeted googling can generate 2           the search in the medical record?”
This mandate extends to the                      types of information, the first coming            • “How do I monitor my motivations
unprofessional use of social media by            from the patient directly. Physicians may          and the ongoing risk-benefit profile
other physicians. Difficulties inherent           understandably be unsure how to use                for searching?”87

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PEDIATRICS Volume 147, number 3, March 2021                                                                                              7
It is generally advisable to disclose                social media policies of their             10. Searching for patient information
any relevant patient information                     health care organization and any               through the Internet or social
discovered through the Internet or                   professional society to which                  media should have a specific
social media to the patient so that                  they belong.                                   purpose with clear clinical
everyone is working with the same                 5. Independent practitioners                      relevance. Any information
set of facts. This disclosure is                     should develop social media                    obtained through this route
especially important before entering                 policies for their practices to                should be shared directly with
any information gleaned through that                 protect patients and clarify                   the patient to maximize
route into the patient record.88                     expectations. These policies                   transparency and before
                                                     should be in writing and widely                recording any such information
                                                     distributed to all staff and                   in the patient’s chart.
CONCLUSIONS
                                                     clinicians. If restrictions on             11. Pediatricians should monitor
Social media can be a useful tool in                 communicating with patients are                their online profile to protect
the practice of medicine by educating                in place in such policies, this                against inaccurate postings.
both physicians and patients,                        should be shared with patients.                Negative online reviews warrant
expanding access to health care,                     Given advances in technology,                  a thoughtful response that
identifying high-risk behaviors,                     these policies should be                       honors confidentiality
contributing to research, promoting                  reviewed regularly and updated                 requirements, including the fact
networking and online support,                       as needed.                                     that the reviewer is or was the
enhancing advocacy, and nurturing                 6. Conflicts of interest, including in             physician’s patient.
professional compassion. At the same                 tweets, blog postings, and media           12. Pediatricians should recognize
time, there are confidentiality,                      appearances by pediatricians,                  that providing specific medical
privacy, professionalism, and                        should be disclosed.                           advice to an individual through
boundary issues that need to be                                                                     social media may create
considered whenever potential                     7. Pediatricians should use
                                                     a HIPAA-compliant secure site                  a physician-patient relationship
interactions occur between                                                                          that may have documentation,
physicians and patients via social                   with encryption when
                                                     communicating about health care                follow-up, state licensing, and
media. The following                                                                                liability implications.
recommendations can help                             or rendering advice directly to
pediatricians use social media                       patients or families. Individually
appropriately and effectively.                       identifiable protected health
                                                                                                LEAD AUTHORS
                                                     information should not be shared
                                                     through social media without               Robert Macauley, MD, FAAP
                                                                                                Nanette Elster, JD, MPH
RECOMMENDATIONS                                      documented authorization from              Jonathan M. Fanaroff, MD, JD, FAAP
                                                     the patient or guardian.
    1. Pediatricians who choose to use
       social media should have                   8. Before posting on social media,
                                                     protected health information               COMMITTEE ON BIOETHICS, 2019–2020
       separate personal and
       professional social media pages,              should be deidentified (and                 Robert Macauley, MD, FAAP, Chairperson
                                                     clearly noted to be so) and                Ratna Basak, MD, FAAP
       with patients and their parents
                                                     presented respectfully.                    Gina Marie Geis, MD, FAAP
       directed to the professional page.                                                       Naomi Tricot Laventhal, MD, FAAP
    2. A pediatrician’s personal page             9. Professional boundaries should             Douglas J. Opel, MD, MPH, FAAP
       should have adequate privacy                  be maintained in the use of social         Mindy B. Statter, MD, FAAP
       settings to prevent unauthorized              media. Accepting (and certainly
       access. Professional pages should             initiating) friend requests from
                                                                                                LIAISONS
       be set to prevent tagging.                    current patients is discouraged. It
                                                                                                Mary Lynn Dell, MD, DMin – American
    3. It is wise to pause before posting,           is up to the pediatrician’s                Academy of Child and Adolescent Psychiatry
       given that information posted                 discretion whether to accept such          Douglas S. Diekema, MD, MPH, FAAP –
       online can exist in perpetuity and            requests from former patients. It          American Board of Pediatrics
       can be captured and                                                                      David Shalowitz, MD – American College of
                                                     may be appropriate to accept
                                                                                                Obstetricians and Gynecologists
       redisseminated by viewers                     a friend request from a patient’s          Nanette Elster, JD, MPH – Legal Consultant
       before it can be deleted.                     parent if the physician’s
    4. Pediatricians should follow state             relationship to that person
       and federal privacy and                       extends beyond the clinical                STAFF
       confidentiality laws as well as the            environment.                               Florence Rivera, MPH

                     Downloaded from www.aappublications.org/news at Oregon Health & Science University on March 2, 2021
8                                                                                                    FROM THE AMERICAN ACADEMY OF PEDIATRICS
COMMITTEE ON MEDICAL LIABILITY AND                     Susan M. Scott, MD, JD, FAAP
RISK MANAGEMENT, 2019–2020                             Laura J. Sigman, MD, JD, FAAP                          ABBREVIATIONS
                                                       W. Michelle Terry, MD, FAAP
Jonathan M. Fanaroff, MD, JD, FAAP,                                                                           AAP: American Academy of
                                                       Robert A. Turbow, MD, JD, FAAP
Chairperson                                                                                                        Pediatrics
Steven A. Bondi, JD, MD, FAAP                                                                                 HIPAA: Health Insurance Portabil-
Richard L. Oken, MD, FAAP                                                                                            ity and Accountability Act
John W. Rusher, MD, JD, FAAP
                                                       STAFF
Karen A. Santucci, MD, FAAP                            Julie Kersten Ake

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2021 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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