Nothing Is Temporary, and the Past Can Haunt You
Social media has become ubiquitous in recent years, and it carries the ability to connect people across the world in ways previously unimaginable. For the practicing surgeon, social media offers several personal and professional benefits, including peer networking, education, e-mentorship, marketing, recruitment, and patient outreach. However, most social media platforms were not designed for professional use, and surgeons can suffer negative consequences from improper social media use that can overshadow the proposed benefits. To avoid the dangers and pitfalls of social media, surgeons must understand the technology and the associated risks. This will allow them to maintain online professionalism at all times. This article focuses on the different ways that improper use of social media can damage the surgeon if he or she does not approach the concept carefully.
Without a doubt, social media is becoming more prevalent and more powerful over time. Facebook1 is perhaps the bestknown example, boasting 1.74 billion monthly active users worldwide,2 including 71% of Americans. Facebook’s yearly revenue continues to increase at nearly exponential rates, and was estimated to be $27.64 billion dollars for 2016.3 Twitter, Inc.4 is another well-known social media platform with an estimated 317 million monthly active users in 2016.
While Facebook and Twitter have long been seen as the towering leaders in social media, it is evident that new platforms will continue to emerge while others lose prominence over time, reflecting the general public’s relatively short attention span. For example, Instagram6 recently surpassed Twitter in popularity with 600 million monthly active users in 2016.7 Social media use among health care workers in the United States has typically mirrored that of most Americans, although reported statistics have varied based on study methods. For example, anonymous surveys have reported higher rates of utilization for physicians and trainees, while other studies that relied on third-party identification of profiles likely underestimated utilization, perhaps due to the widespread use of pseudonyms and other methods to maintain anonymity.
We recently published two studies regarding Facebook use among surgical residents and faculty surgeons, and determined utilization to be a modest 32 and 26%, respectively.8,9 We then conducted a survey of general surgery program directors, where we found a self-reported rate of Facebook use to be much higher at 67%.10 This is similar to a 2010 survey conducted by the American College of Surgeons (ACS) that found utilization of Facebook among surgeons to be 54.8%.11 Since that survey was conducted 7 years ago, it is safe to assume that utilization has increased over this time
This hashtag was included in 5,354 tweets created by 1,000 unique users, generating 14.7 million impressions, meaning that the hashtag was viewed on an individual’s Twitter feed 14.7 million times. The following year, was used for the Clinical Congress in Chicago, and dwarfed the 2014 numbers with nearly 56 million impressions.14 For the 2016 Clinical Congress in Washington, DC, was included in over 20,000 tweets by almost 5,000 individual users, and generated nearly 80 million impressions.13 This exponential growth speaks to the growing popularity of the social media platform.
Unprofessional Conduct among Physicians on Facebook
physicians receive little to no education on how to properly maintain online professionalism. As a result, there is often an unintentional overlap between the surgeon’s personal and professional lives on platforms such as Facebook and Twitter. Some pictures and comments may have been meant for a surgeon’s friends and family, while others were aimed at professional colleagues, patients, or the general public. Short of creating entirely separate accounts for each intended purpose, there is no good way to separate these potential uses. If a user posts links to funny cat videos, pictures of dinner plates, and discussion of politics, then switches gears and posts journal articles or links that promote the surgeon’s hospital or practice, it is unlikely that a single platform will hit these different targets with equal efficacy. The intended audience may not have an interest in (or worse: may take offense to) the posts aimed at a different demographic. Another potential consequence of the poorly defined audience is a surgeon unintentionally sharing content with the public.
Twitter is relatively straightforward as all posted content is viewable by the public. However, Facebook can be more confusing to the novice user, as the privacy settings contain several options designed to limit the ability of the general public to view certain posts. These settings can be adjusted for different content, sharing one picture with the public while reserving others for “friends only.” This level of complexity can lead to mistakes, and content intended for friends and family can be seen by patients and professional contacts, a misstep which will be further highlighted in the upcoming section on “examples of bad behavior.” Similarly, if shared or re-posted by a contact who does not have such privacy settings in place, these posts intended to the “private” may be discoverable by a wider audience. Thus, there is no guarantee that any posting will not eventually be able to be viewed by the general public.
The previous section highlighted the profound reach of social media because this frames a discussion of risk. Social media is “big business” because it has such a large audience and demonstrates very high utilization among surgeons and patients alike. Therefore, consequences of bad behavior can be swift and severe. This section outlines the reasons why social media can be dangerous to surgeons and trainees alike
Even when personal and professional lives are kept separate, surgeons using social media are still subject to the enormous body of misinformation on the Internet. In general, the accuracy of what is being said by surgeons or about surgeons cannot be guaranteed and there is no good way to separate fact from opinion. Unlike medical journals, content on the Internet is typically not subjected to rigorous peer review, and so biased opinions and unproven interventions may receive undeserved attention. Similarly, regional and national scientific meetings require the presenters to possess a certain level of expertise in the chosen subject of discussion to be given the privilege of time on the podium. On Twitter or Facebook, there is no such requirement for expertise to speak from this “virtual podium.” Instead, the only necessity is an audience. Celebrity Jenny McCarthy has been known to share her opinions on diseases such as autism with her 1.4 million followers on Twitter.15 Kim Kardashian West has 54.9 million Twitter followers.16 Meanwhile, the Annals of Surgery17 has 20,200 followers and the American College of Surgeons18 has 34,800.
In considering the integrity of the source vis-à-vis the size of the audience, consider the following: If a scientific journal publishes conflicting (but peer-reviewed) information to a pop culture icon’s opinion, which information is more likely to be disseminated, dare we say believed as fact (see the articles in this issue about how social media information gets disseminated and about verifying information). Adding to the inaccuracy of information presented on social media is the presence of fake profiles. Essentially any Internet user can create a profile and claim names and pictures; so, a surgeon or institution’s identity can be stolen and their image subsequently damaged. In 2014, the American Society of Colon and Rectal Surgeons had their logo used in the profile of a South American hospital, potentially giving the impression of authenticity or endorsement. It took several months to get this changed and there is little authority to police against such actions. Other accounts may not steal identities, but can still cause significant damage through spamming users or promoting other agendas and products.
user privacy, and so the user should never assume that posts and pictures are fully restricted from public view. These platforms also do not have adequate security to prevent Health Insurance Portability and Accountability Act (HIPAA) violations; so, any identifiable patient information shared on these sites, even if “protected” by the user’s privacy status or the use of a private group, is a direct violation that can result in patient compromise and physician punishment (that can include substantial fines or penalties, employment termination, or other adverse consequences).
Examples of Bad Behavior and Consequences
With the advent of social media and Internet search engines, it has become much more difficult for surgeons to remain anonymous and hidden from their patients when they engage in activity that they would prefer to keep separate from their professional identity. If this behavior is shared on social media, perhaps with friends and family as the intended audience, there is potential for the general public to receive a more intimate and untarnished snapshot of their surgeon. This can include undesirable behavior such as binge drinking, foul language, and sexually explicit or politically charged remarks. Even if none of the behavior could be interpreted as unprofessional, there is still potential for breaches in privacy, and the public can obtain access to family facts and photos that the surgeon did not intend to share with them.
Several avenues for undesirable dissemination of this content exist, but one that likely does not receive enough emphasis is the surgeon’s extended network. Often a Facebook user will have hundreds of “friends,” and these people have access to most of the surgeon’s Facebook content. While these friends may be close to the surgeon, they often also include networking contacts, childhood and school acquaintances, and perhaps even people disguised as friends who actually have malicious intent.
Fairness Is Seemingly Irrelevant
Any discussion of online professionalism will eventually come to a disagreement about what is considered unprofessional behavior for surgeons, a label that is inherently subjective. Some would opine that online demonstrations of binge drinking, shooting guns, and discussing polarizing, religious, and political topics are inappropriate for physicians. Others would argue that physicians should have the right to express themselves as long as their behavior is legal, and being held to higher levels of scrutiny is unfair. Regardless of opinions or perceived justice, the surgeon is ultimately subject to the court of public opinion.
Author: J. Langenfeld