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The use of blogs, Facebook and similar social networking sites is rapidly expanding and, when compared with e-mail, may be having a significantly different impact on the traditional doctor-patient relationship. Characteristics specific to these online platforms have major implications for professional relationships, including the ‘Facebook effect’ (the relative permanence of postings) and the ‘online disinhibition effect’. The present practice point illustrates relevant ethical considerations and provides guidance to paediatricians and others concerning the prudent professional and personal use of social networking media.
L’utilisation des blogues, de Facebook et de sites de réseautage social similaires prend une expansion rapide. Par rapport aux courriels, les réseaux sociaux peuvent avoir des répercussions très différentes sur la relation classique entre le médecin et son patient. Les caractéristiques propres à ces plateformes virtuelles ont des conséquences considérables sur les relations professionnelles, y compris « l’effet Facebook » (la permanence relative des textes affichés) et « l’effet de désinhibition virtuelle ». Le présent point de pratique illustre les considérations éthiques pertinentes et oriente les pédiatres et les autres professionnels de la santé quant à l’utilisation professionnelle et personnelle prudente des réseaux sociaux.
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Since the early 2000s, new ways of communicating have been developing over the Internet; initially, discussion forums and blogs, followed by social networking sites like Facebook, Myspace, LinkedIn and Twitter. According to a 2010 Pew Internet survey (1), 95% of Americans aged 18 to 33 years are online, 83% use social networking sites and 43% read blogs. Over the past two years, an increasing use of social media has been noted for all age groups. A similar increase in usage has been noted in the medical profession. A Canadian Medical Association (CMA) survey (2) demonstrated that 51% of physicians use Facebook, 26% participate in social networking sites for physicians and 14% have a practice website. The extent of use of these new forms of communication in paediatrics is not known, but it is assumed to follow these general trends.
A recent CMA guideline outlines various social media uses, debates their advantages and disadvantages, and recommends that Canadian physicians be aware of their impact on professional practice (3). A frequently cited Canadian Paediatric Society practice point offers practical suggestions for the professional use of e-mail communication in paediatrics (4). Many of its recommendations also apply to social media use, but newer platforms also have specific characteristics that may be impacting the traditional doctor-patient relationship differently than e-mail communication. For example, these platforms are designed so that information can spread globally and very rapidly (eg, by ‘going viral’). Known as the ‘Facebook effect’ (5), this feature allows the instant sharing of data by people interested in the same topics. The downside of public information dissemination is that it is also accessible by persons who are not necessarily the intended recipients. Information posted on social media sites has the inherent potential to reach a much larger audience than targeted e-mail communications. Thus, any material posted on such sites should be assumed to be public. In addition, ‘footprints’ (6), meaning information that is left behind even after an initial thread is deleted, are difficult, if not impossible, to remove from the public domain. The permanent record left by temporary postings on these platforms can have far-reaching effects.
The present practice point reviews three Internet applications with particular relevance for the traditional doctor-patient relationship: patients’ blogs, physician websites and social networking platforms like Facebook. Pertinent ethical issues include privacy, patient confidentiality and medical professionalism. A distinction is made between professional versus personal use of social networking media. Blogs written by medical students, health care professionals and physicians are not discussed because they were addressed in the practice point cited above (4).
Patient blogging in paediatrics is common (7). Adolescent patients and the parents of paediatric patients use personal web pages that permit comments by visitors. Some ‘support blogs’ play an important role for the parents of sick children, complementing or even replacing more traditional support groups. On these blog sites, patients can report difficult clinical experiences and elicit supportive comments from visitors. However, three major problems have arisen in relation to patient blogging (7). The first two touch on privacy and confidentiality issues. In some cases, fellow patients or health care providers are so well described that they are identifiable, resulting in a breach of confidentiality. Patients may also share, inadvertently, private and sensitive information about themselves without fully considering the consequences. Health care team members may be offended by patient comments, to the point of affecting the relationship adversely and possibly impacting patient care. The risk of an impaired relationship is particularly strong if a patient’s dissatisfaction has not been expressed previously and in person.
Many physician websites offer basic information on office practice and patient care (eg, opening hours, medical credentials, or general health topics such as chronic or infectious diseases, immunization, nutrition, therapies and medications) (8). Several ethical considerations are relevant to this type of site. Recommending particular therapies or medications in a public forum can be a form of advertising, and any conflicts of interest need to be disclosed. Also, when providing medical or treatment advice online, physicians have both a legal and ethical obligation to keep the site current and up-to-date as well as to respond to personal concerns in a timely fashion. Finally, there is the possibility that a physician’s time spent on responding to website requests intrudes on or even takes priority over office-based care, a tendency which may increase as some physicians come to request remuneration for this type of care.
Facebook and similar sites have been used successfully by universities, hospitals, physicians and researchers for professional reasons, in particular, for promotion. However, the personal or ‘fun’ use of Facebook may be influencing the traditional doctor-patient relationship more than its professional uses. Facebook users populate their profiles with wide ranging information, including demographics, work affiliations and political or religious opinions. Favoured links, photographs and videos of users, friends and family often complement personal information. Technically, only virtual ‘friends’ selected by the site owner are allowed to access personal data. In fact, however, users cannot fully control who has access to their site despite high levels of privacy protection. Four major problem areas have emerged: issues of civil liability relating to breaches of patient confidentiality by health care providers (9); the posting of unprofessional content (10,11); job loss because of a damaging disclosure by a profiled individual or some third party; and finally, physicians have not always applied appropriate privacy options, making personal information public inadvertently (11).
Certain professional boundaries within the doctor-patient relationship can be blurred by becoming friends on a social networking site. Patients sometimes post clinical or personal information they have withheld from their doctor as being irrelevant or too ‘sensitive’. For example, teenagers may not reveal that they use recreational drugs or alcohol. Parents may tell ‘virtual’ friends about their dissatisfaction with a medical team without first telling their doctor. Similarly, doctors have traditionally maintained a measure of professional distance from patients, about whom they generally do not wish to know their misadventures or foibles. However, becoming a Facebook friend and allowing access to private information can blur these boundaries, especially given the ‘online disinhibition effect’ (12). This term refers to the tendency to self-disclose or act more intensely online than in person (12). Inadvertent sharing of private information on either side can give rise to tension or distrust that may impede the therapeutic relationship.
In response to the inherent risks of new media for the doctor-patient relationship, universities, professional and medical associations, including the Canadian Medical Protective Association, are developing guidelines around Internet conduct and virtual networking (4,13–17). Key recommendations include the following:
Blogs, social media and physician websites are the way of the future. All new media are in the public domain and physicians must be continually mindful of privacy, prudence and professionalism when communicating online.
This document has been reviewed by the Canadian Paediatric Society’s Adolescent Health and Community Paediatrics Committees.
BIOETHICS COMMITTEE: Susan G Albersheim MD (past member); Kevin W Coughlin MD (Chair); Pascale Gervais MD (Board Representative); Marie-Claude Grégoire MD; Robert I Hilliard MD; Ian Mitchell MD; Thérèse St-Laurent-Gagnon MD (past member)
Principal authors: Thérèse St-Laurent-Gagnon MD; Kevin W Coughlin MD
The recommendations in this document do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. All Canadian Paediatric Society position statements and practice points are reviewed on a regular basis. Please consult the Position Statements section of the CPS website (www.cps.ca) for the full-text, current version.