Status update: Mark Zuckerberg, founder of Facebook, marries Dr Priscilla Chan. Their marriage represents the ongoing integration of social media and medicine—for better or worse, for richer or for poorer, in sickness and in health.

Social media is the broad spectrum of online communication tools providing channels for connecting people.[1] Social media enables real-time sharing of text, audio, photos, and videos to both active and passive users. This evolving online community, known as Web 2.0, is a second generation of Internet. Web 2.0 is defined by interactive applications that promote user-generated and user-controlled content.[2] Social media has emerged as part of the construct of Web 2.0.

Consider these social media facts: Facebook has over 900 million active users. Twitter users are uploading 340 million tweets daily. This flood of user information is being catalogued by increasingly sophisticated methods such as the hashtag (“#” symbol), categorizing trending topics and posts.[3] The proliferation of social media is promoting a change in the way people use the Internet from purely recreational to encompass professional and clinical usages. Incorporation of social media and its overarching infrastructure of Web 2.0 into health care is increasing and generating discussions in the medical community.[2] 

Social media users are everyday patients. Medical information searches are being performed by 80% of Internet users.[4] These searches for medical information are the third most popular Internet activity.[4] Patients are engaging in social media using the tools of Web 2.0 as an adjuvant to traditional methods of accessing health care. 

Physicians use social media too. According to the 2011 CMA members’ survey, 50% of physicians in Canada have a Facebook account and 43% of physicians report contributing to an online medical forum.[5] The 2011 BCMA members’ survey found that 37% of respondents reported using Facebook and 6.4% of respondents reported contributing to an online blog.[6] These surveys do not differentiate between physician time spent using social media for personal and for practice purposes. However, there are emerging examples of medical professional engagement in social media including social networking sites exclusive to physicians, such as Medscape Connect (www.medscape.com/connect [11]) and Sermo (www.sermo.com [12]). Specific physician blogs are also gaining popularity, including Kevin MD (www.kevinmd.com/blog/ [13]) and 33 Charts (www.33charts.com [14]).

Questions persist regarding whether physicians should be engaging in social media professionally, the benefits and risks of physician participation in social media, and recommendations physicians should follow to prevent any medicolegal consequences associated with these nontraditional forms of patient-physician interactions.    

Why physicians should use social media: #Benefits

Enhance communication (physician to patient)
Studies of physician interruption times and patient comprehension indicate both quantitative and qualitative communication barriers.[7,8] Social media has the potential to help alleviate these barriers by influencing patient participation, autonomy in health decisions, and providing a level playing field within the Web 2.0 sphere. For example, Breast Cancer Answers (www.breastcanceranswers.com [15]) is a physician operated website enabling patients to submit questions and receive video answers. Oncology experts record videos in lay terms, helping patients learn about their diagnosis while in a receptive state and a comfortable environment.

Enhance communication (physician to physician)
Social media can be a powerful tool for communicating with colleagues. Professional Facebook pages, Twitter accounts, and blogs enable physicians to easily share useful links to articles and videos. Physicians with common interests can disseminate information by creating online learning networks.[9] Similarly, social media tools have the potential to enhance medical education. For example, Twitter accounts may augment medical trainee education through announcements, exam preparation, and locating CME resources.[9] Physicians are using Twitter to post questions with links to blogs for active discussion.9 Physicians who passively follow Twitter accounts will still gain access to these additional educational resources. 

Health promotion and compliance
Social media has been successful in encouraging health improvement and behavioral changes. A pilot study at the University of Illinois evaluated the incidence of chlamydia among young adults through a social networking intervention.[10] The participants used a Facebook page that addressed signs, symptoms, treatment, screening, and prevention of chlamydia infections. The results included a 23% increase in self-reported condom use and a 54% reduction in identified chlamydia cases.[10] 

Patients’ adherence to medication regimes may also improve through social media programs. Studies from Castano and colleagues and Horvath and colleagues have shown that daily text messaging enhances birth control pill and anti-retroviral therapy compliance in target populations.[11,12] Social media could be used as a follow-up method of communicating with patients to reinforce key themes, improve treatment success, and manage disease.

Tracking disease
Social media facilitate information flow from patients to physicians and to medical agencies through its interactive nature. Increased volume of information and faster information transfer is useful for surveying disease outbreak. For example, the website Flu Near You (www.flunearyou.org [16]) enables users to report their health status, thereby identifying potential disease sentinels.[13] Google Flu Trends (www.google.org/flutrends/ca/#CA [17]) compares volumes of flu-related search activity, reporting flu incidence rates and mapping the data in real time. 

The Influenza Division of the Centers for Disease Control and Prevention (CDC) monitors Google Flu Trends as a method of detecting early response opportunities.[13] There is evidence of Twitter tracking cases of influenza-like illnesses. During the 2009 H1N1 pandemic, tweets including key terms “flu,” “swine,” and “influenza” tracked user concerns and helped to predict flu outbreaks 1 to 2 weeks earlier than the CDC.[14] 

Positive online identity
Patients may expect their physicians to maintain a level of online connectedness, as evidenced by the common practice of searching one’s doctor online. Search engines, such as Google, Yahoo, and Bing filter website rankings in a complex socioeconomic manner. Consequently, physician-rating websites often lead the search results. The content of these websites do not always accurately convey measures of medical competence. A strong physician presence within social media can provide patients with professional online content that is directly controlled.[15] The presence of this online physician content can counterbalance opinionated information, contribute expert advice, and validate posted material.

Why physicians should be cautious when using social media: #Risks

Confidentiality
Social media provides medical professionals with online spaces to discuss experiences within their practices. However, material published on the Internet is public. Physicians must exercise caution, including removing patient identifiers, when discussing details of patient cases. Physicians must preserve the legal and ethical responsibilities for protecting physician-patient confidentiality.[16]

Physician-patient relationship
Social media may blur the boundaries between personal and professional lives. Physicians may be unable to regulate patient access to their online personal information. Content posted to social media spaces has a greater risk of widespread dissemination due to imperfect privacy settings. The combination of privacy and access issues can compromise the integrity of the professional physician-patient relationship.

Defamation
Physicians have the right to engage in professional conversations and debates through social media, but it’s important to remember that defamation law applies to content online. Defamatory statements are those that are published to a third party, person, or group, which identify a patient, colleague, or person and damage the subject’s reputation.[17] People often feel less inhibited when engaging in online interactions, and may express ideas that would not normally be communicated in face-to-face meetings. Additionally, online content can easily be taken out of context. Contributing to Web 2.0 through social media with an anonymous user name does not guarantee anonymity. Physicians are considered experts with a fiduciary obligation to their patients and need to exercise sound judgment when online.

Professionalism
Physicians may freely maintain personal online profiles, but it is important to consider the implications of uploaded content to one’s professional reputation. Photos, videos, and status updates can be captured and shared immediately elsewhere online. Unprofessional online behavior can not only compromise a physician’s credibility (and the credibility of the institution where he or she is employed), but can erode the public’s confidence in the medical profession.[18] 

Maintaining professionalism in social media use is especially apparent for medical trainees. Medical students are often technologically savvy, but are just beginning to develop their sense of professionalism. They may not understand that publicly available content directly reflects their professional reputation.[19] A study at the University of Florida evaluated the Facebook profiles of all medical students and residents within their program.[19] Results showed that the majority of accounts listed at least one form of personally identifiable information. Some accounts had visible content that could be interpreted negatively in the context of professional conduct, including a majority of profiles (70%) displaying photos of alcohol consumption.[19] These results show the importance of training medical students and residents to maintain professionalism when using social media and be accountable for their online behavior.

How to use social media safely: #Recommendations
Should they choose to maintain an online presence, physicians and medical trainees should strive to use social media in its appropriate context both personally and professionally, in order to protect themselves, their patients, and the medical profession. The recommendations listed in the  can help guide physicians toward safe and effective use of social media.[1,16,18,20]

Acknowledgments
Thank you to Dr Sam Bugis and Mr Rob Hulyk for their guidance on this article as part of a summer internship at the BC Medical Association.

References

1.    Canadian Medical Association. Policy paper. Social media and Canadian physicians: Issues and rules of engagement. 2011. Accessed 28 May 2012. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD12-03.pdf [18].
2.    Van De Belt TH, Engelen LJ, Berben SA, et al. Definition of Health 2.0 and Medicine 2.0: A systematic review. J Med Internet Res 2010;12:e18.
3.    Twitter. What are hashtags (“#” Symbols)? 2012. Accessed 27 June 2012. http://support.twitter.com/articles/49309-what-are-hashtags-symbols# [19].
4.    Fox S. Pew Research Center Internet and American Life Project. 2011. Accessed 28 May 2012. http://pewinternet.org/Reports/2011/HealthTopics.aspx [20].
5.    Canadian Medical Association. Social media use by physicians. 2011. Accessed 30 May 2012. www.cma.ca/advocacy/social-media-use-physicians [21].
6.    British Columbia Medical Association. BCMA Membership Survey. 2011. Accessed 13 December 2012. www.bcma.org/2012-bcma-member-survey-results [22].
7.    Li HZ, Krysko M, Desroches NG, et al. Reconceptualizing interruptions in physician-patient interviews: Cooperative and intrusive. Commun Med 2004;1:145-157.
8.    Travaline JM, Ruchinskas R, D’Alonzo GE Jr. Patient-physician communication: Why and how. J Am Osteopath Assoc 2005;105:13-18.
9.    Yamout SZ, Glick ZA, Lind DS, et al. Using social media to enhance surgeon and patient education and communication. Bull Am Coll Surg 2011;96:7-15.
10.    Jones K, Baldwin KA, Lewis PR. The potential influence of a social media intervention on risky sexual behavior and chlamydia incidence. J Community Health Nurs 2012;29:106-120.
11.    Castano PM, Bynum JY, Andrés R, et al. Effect of daily text messages on oral contraceptive continuation: A randomized controlled trial. Obstet Gynecol 2012;119:14-20.
12.    Horvath KJ, Danilenko GP, Williams ML, et al. Technology use and reasons to participate in social networking health websites among people living with HIV in the US. AIDS Behav 2012;16:900-910.
13.    Schmidt CW. Trending now: Using social media to predict and track disease outbreaks. Environ Health Perspect 2012;120:A30-A33.
14.    Signorino A, Segre AM, Polgreen PM. The use of Twitter to track levels of disease activity and public concern in the US during the influenza A H1N1 pandemic. PLoS One 2011;6:e19467.
15.    Tilt A, Mermel C, Conrad C. How surgical residents use social media. Surgery, 2011;150:5-6.
16.    The Canadian Medical Protective Association. Using social or professional networking websites can breach confidentiality. 2010. Accessed 13 December 2012. www.cmpa-acpm.ca/cmpapd04/docs/resource_files/perspective/2010/02/com_p1002_7-e.cfm [23].
17.    Australian Medical Association. Social Media and the Medical Profession: A guide to online professionalism for medical practitioners and medical students. 2010. Accessed 13 December 2012. https://ama.com.au/social-media-and-medical-profession [24].
18.    British Medical Association. Using social media: Practical and ethical guidance for doctors and medical students. 2011. Accessed 28 May 2012. http://bma.org.uk/practical-support-at-work/ethics/ethics-a-to-z [25].
19.    Thompson LA, Dawson K, Ferdig R, et al. The intersection of online social networking with medical professionalism. J Gen Intern Med 2008;23:954-957.
20.     College of Physicians and Surgeons of BC. Professional standards and guidelines: Advertising and communicating with the public. 2012. Accessed 13 December 2012. www.cpsbc.ca/publications-resources/professional-standards-guidelines [26].

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Ms Budd is a medical student at the University of British Columbia in the class of 2014, and participated in the BCMA medical student intern program in the summer of 2012.