A friend recently came to me with a concern. Her former OB/Gyn had approached her with a request to be a friend on Facebook. It was a request that made my acquaintance uncomfortable because she felt that the relationship with her doctor had been a professional one, not a friendship.

In many ways, today’s social networking systems are wonderful tools, bringing people together — and no longer just the domain of teenagers. Adult Internet users participating in online social networks quadrupled from 8 percent to 35 percent between 2005 and 2008. Lenhart, Amanda: “Adults and Social Network Web Sites.” Pew Internet and American Life Project (Jan. 14, 2009). But these networking systems raise a set of issues that require us to think about confidentiality and professionalism in a new way.

CURRENT USAGE AND TRENDS

Some large health systems are now using social sites as a marketing tool. Edward Bennett, director of Web strategy at the University of Maryland Medical System, has been tracking how hospitals currently use social media. Bennett has found that 142 hospitals have YouTube channels, 109 have Facebook pages, 213 use Twitter and 26 have blogs. Bennett, Ed: “Hospital Social Network List.” (Found in Cache; posted June 15, 2009; accessed June 19, 2009.) Considering the fact that there are more than 5,000 hospitals in the United States, these numbers may not seem substantial, but it is significant that some of the biggest names in health care are among them. The Mayo Clinic in Rochester, Minn., is one of the early innovators. Its manager of Syndications and Social Media, Lee Aase, is busy harnessing social media tools to promote The Mayo Clinic, including by encouraging patients to make video testimonials via YouTube. He is, according to an article in the Minneapolis/St. Paul Star Tribune, a “walking, talking, blogging, Twittering, Facebooking, YouTubing force who’s blasting Mayo into the social networking world faster than you can say ‘Mayo Brothers.’” Yee, Chen May: “Mayo Turns to Social Media to Reach Out to Potential Patients“. Star Tribune, (April 29, 2009). But is the use of social networking systems a radical departure from the use of other Internet marketing tools used by health care organizations? Memorial Sloan-Kettering Cancer Center in New York, for instance, has pictures on its Web site with close-ups of patients’ faces, and the line: “Cancer. Where You’re Treated First Can Make All the Difference.” http://www.MSKCC.org, (accessed June 15, 2009). It is not uncommon to have testimonials used as marketing tools. For example, St. Jude’s Children’s Research Hospital in Memphis, Tenn., has a “Patient of the Month” page, featuring a different child every month.

But hospitals’ official Web sites are monitored to protect patient confidentiality. Any patient-identifying information would and does require consent and is more easily controlled. Individual social networking sites don’t have the same type of oversight. Because this is a relatively new phenomenon, it will take time — and some missteps — before the wrinkles are smoothed out.

A PARTICULAR PROBLEM FOR YOUNG PROFESSIONALS

Many a 40-plus-year-old can recall with a wince the embarrassing thing he or she did at the company picnic — that thing that prevented a promotion. Such early missteps, while embarrassing, soon fade into history. Not so those things posted on the Internet, which can live on, it seems, into perpetuity. Younger medical professionals and medical students still working their way through the college system are used to social networking sites, and they are less comfortable with the self-censorship that older generations have learned to employ in order to fit into the professional world. As evidence of this, researchers at the University of Florida examined Facebook profiles of UF medical students and residents and found that a significant number shared personal information that it would be unprofessional to share with patients. Facebook use was prevalent among UF students, with 44 percent of them having online profiles, but only 37 percent bothering to make their profiles private.

What kind of personal information were students sharing? More than half revealed their sexual orientation, nearly half discussed their political views and close to 60 percent indicated their relationship status. When UF researchers took an in-depth look at ten randomly selected profiles, they found that seven included photos of the student drinking alcohol (some also implied excessive drinking) and several had joined groups that could be seen as sexist or racially charged. (“Physicians Looking for Trophy Wives-in-Training”) or (“I Should Have Gone to a Blacker College”). Lockette, Timothy: “Future Doctors Share Too Much on Facebook, UF Researchers Say.” University of Florida News, (July 10, 2008).

Another group of first-year medical students once made a video at the end of the year that contained humor concerning the cadavers used for teaching purposes. The spoof and parody was an example of the gallows humor that is well accepted in the medical community — a way to bond while mired in the serious and often depressing business of caring for sick and injured people. But what happened when, in 2007, that video was published on YouTube? A private moment of lightness became a public document, resulting in a great deal of controversy at the university and elsewhere. Some of the students thought that curtailing the video’s dissemination violated their first amendment rights. Many senior faculty found the video distasteful and worried about potential public relations fallout. After much negotiation, parts of the video remained on the Web, but neither side was satisfied with the outcome. Farnan, Jeanne et al.: “The YouTube Generation: Implications for Medical Professionalism.” Perspectives in Biol and Med, 51.4 (Autumn 2008): 517.

PRIVATE TO PUBLIC

Part of the challenge is in understanding the transition from a private conversation to a public forum. It is one thing to have a skit performed for a small group of insiders who appreciate the insider humor and see the skit for what it is: a relief from the burdens of caring for very sick people. It is another for the public to see it as a representation of how physicians view their role in medicine. What may be a lighthearted and cathartic moment for the students could feel like an insensitive slap in the face to those who have contributed the remains of their loved ones to science.

And of course there are repercussions for not representing oneself professionally online. Almost 30 percent of job applicants across all fields have been denied employment when potential employers discovered information about them posted over the internet. Parker, K: “Web Warning for Youths: Employers Are Watching.” Real Clear Politics, March 9, 2007.

Evidence of good judgment and trustworthiness is even more important in health care than in many other fields because health care professionals are entrusted not only with the physical care of patients, but with care of their privacy rights. For young medical professionals, the fact that they are no longer simply individuals communicating with their friends, but representatives of their profession communicating with the world, is a concept that must be grasped if trouble is to be avoided.

CROSSING THE PATIENT PRIVACY LINE

Sensitivity to patient privacy and treating patients with dignity is not only required by law, but by the standards of medical professionalism. When medical personnel use poor judgment regarding social networking systems, they may harm not only their professional status, but also the privacy rights of patients. This can leave them open to disciplinary action and civil liability.

PHOTOS AND VIDEOS ON THE INTERNET

Two nurses in Geneva, Wis., were recently terminated after they took cell phone photos of an X-ray showing a sexual device lodged in a patient’s rectum, and posted it on Facebook. Scott, Dwight: “Facebook Firings Show Privacy Concerns with Social Networking Sites.” Healthcare Risk Management, May, 1, 2009. Although the firing was in accordance with hospital policy, and the hospital may not face HIPAA sanctions, it surely has taken a public relations hit. Likewise, last year a surgical nurse in Stockholm, Sweden, was suspended after she posted photos from brain and back surgeries on Facebook without patients’ consent. Boyes, Roger: “And This Is Me on Facebook … Helping with a Brain Operation.” The Times (London) Aug. 19, 2008: 31. In the Philippines, an unauthorized video of medical staff surgically removing a foreign object from the rectum of a male patient was posted on YouTube without the patient’s consent. During the video, the staff, including doctors and nurses, are shown laughing, cheering and generally being disrespectful. The patient reportedly contemplated a lawsuit. Associated Press: “Philippine Surgeons Goof Off on YouTube” CBSnews.com. (April 16, 2008; accessed June 15, 2009.)

CASUAL CONVERSATION

While these are egregious violations of patient confidentiality, the more worrisome is the casual conversation that social networking sites encourage. Researchers at the University of Pennsylvania examined 271 medical blogs and concluded that while blogging by medical professionals offered great opportunities for sharing information, perspectives and advice among the health community, it also posed the risk that patient confidentiality would be compromised. Lagu, Tara et al.: “Content of Weblogs Written by Health Professionals.” J Gen Intern Med 2008 October 23(10): 1642-1646. The study found that the blogs often reflected poorly on the authors and their professions and that privacy concerns were not given enough priority. More than half (57 percent) provided enough information to indicate the identity of the author. Individual patients were a frequent post topic (42 percent of the blogs), and patients were described in both positive and negative lights. Distressingly, almost 17 percent of blogs that discussed patient interactions included identifying information about either the doctor or the patient, and three went so far as to include photos of the patients.

It is one thing to chat about the work day with friends or family over dinner. It is another to chat about it in a public setting, on a loudspeaker, so that everyone can hear — and that is what postings on the Internet do. A quick Google search for “Medical Malpractice Social Networking Sites” yields hundreds of pages of Web sites opining on the issue. While breaches of patient confidentiality via social networking sites have not produced any reportable cases yet, it may be inevitable as the use of these online tools continues to grow rapidly and exponentially. And it is clear that medical malpractice lawyers, both for plaintiffs and defendants, are looking to see what parties and witnesses are saying and doing on the Web.

SOME RECOMMENDATIONS

Social networking sites are here to stay and, if used wisely, can be an asset to the medical community. But if you are going to use them, some simple rules might be helpful, both professionally and legally:

• If you participate on a personal social network site, make it private. Keep professional relationships professional and personal relationships personal.

• Join a provider site that is limited to other health care providers — and verified to be secure and confidential. An example is Sermo.com, which claims to have generated 30,000 discussions and answered 3 million questions since 2006.

• Use a secure Web site for communication with patients and other physicians. Many large systems are already doing so — Kaiser Permanente, for instance. Innovative solos, such as Brooklyn-based Hello Health, are also reinventing communication with patients and colleagues by using e-mail, instant messaging and even “cybervisits.” Hawn, Carleen: “Take Two Aspirin and Tweet Me in the Morning: How Twitter, Facebook, and Other Social Media Are Reshaping Health Care.” Health Affairs 28, no. 2 (2009).

• Take advantage of educational opportunities. Recently, neurosurgeons at Henry Ford Hospital in Detroit performed an awake craniotomy while telecasting it to some 1,900 others (primarily physicians), while answering Twitter questions. This done was with the consent of the patient, who understood it to be a valuable teaching opportunity. Pinto, Barbara: “Using Twitter to Teach: Surgeons ‘Tweet’ From Operating Room During Brain Surgery” ABC News March 22, 2009.

CONCLUSION

Finally, and perhaps most importantly, remember why medicine is a privilege. People’s lives are entrusted to providers every day. It is a responsibility that requires a professional, trustworthy and patient-centered approach by providers, with the good of the patient foremost in mind. Since we know that trust is the foundation of all patient/physician relationships, physicians violate that trust at their professional and personal peril.

Linda S. Crawford, a member of Medical Malpractice Law and Strategy‘s Board of Editors, teaches trial advocacy at Harvard Law School and has been consulting with defendants on research-based effectiveness at deposition and trial since 1985.