SOCIAL MEDIA

Howmuch of a social media profile can doctors have?Social media have made it harder to maintain a distinction between professional and personal lives.Margaret McCartney looks at the dangers

Margaret McCartney general practitioner

Glasgow, UK

Professionalism and social media can be an uneasy mix. In thepolice force, Freedom of Information data have shown that, inthe past four years, two officers have been sacked, sevenresigned, and over 150 been disciplined for placing“inappropriate” photographs or comments online.1Nurses havebeen sacked after making comments about patients andcolleagues online,2 posting photographs of themselves exposingtheir breasts while in uniform,3 and putting pictures of patientsonline.4 In the United States, four nursing students were expelledafter putting a photograph of themselves with a human placentaon Facebook5; and, in Sweden, a nurse has been disciplined forputting photographs from the operating theatre on the samesocial networking site.6

Doctors have not been immune. In the UK there have beenseveral high profile incidences of tweets or online interactionsthat have ended up in the lay press; one Scottish junior doctorwas controversially suspended over comments made aboutsenior doctors on a website for doctors and students.7

Meanwhile, the BMA has published guidance for doctors andmedical students on how to use social media,8 and the GeneralMedical Council, the UK regulator, is currently consulting onit. There are clear things that doctors should not do, whetheronline or not—namely, break confidentiality or perform illegalacts. The internet means that it is possible to communicatequickly with specialists or colleagues locally or distantly. Butwhile email is private and can be sent with a high level ofsecurity, the trend for online discussion through blogs,discussion forums, or Twitter means that more people can viewwhat doctors are saying to each other about clinical or othermatters.Some websites aimed at doctors—for example, Superego Cafe,the BMJ Group’s doc2doc, and doctors.net—have specificforums for discussing clinical cases. On doc2doc members needto provide proof of relevant medical qualifications beforegaining access to a closed clinical forum. But this isn’t the caseeverywhere. A recent case discussion on a Superego Cafe forum,aimed at psychiatry professionals, contained several specific

details that may have made the patient identifiable not only toherself but also to her friends or community. The forum couldbe accessed and joined by a simple process of obtaining apassword and does not require the user to bemedically qualified,and casual browsers are allowed limited access. Is this wise?Godwin Busuttil is a barrister specialising in media law at 5RBChambers, Gray’s Inn, London, and is a legal adviser to theBMJ. He has several concerns about the use of online media bydoctors. “This is a further example of a wider phenomenon.People feel disinhibited when they go online. A doctortraditionally may have discussed things—such as the subject ofthe blog—with other doctors in the hospital canteen or on thephone but would not have dreamt of putting them on a messageboard where everyone could read them. If a doctor is talking toa colleague, it’s done in a collegial way, in the spirit ofprofessional inquiry. No harm is likely to be done, and theremay actually be a benefit to the patient. But doing it online givesrise to all sorts of concerns about patients’ privacy.” In theSuperego Cafe case, “Although the doctor doesn’t name [thepatient] the facts are distinctive, and she could be identifiableto people who know her. On the other side of the equation, howlikely is it that people who know her personally, as opposed tohealth professionals, are going to be accessing this specialisedsort of forum? Objectively, the risk of disclosure of sensitiveinformation would seem limited, but that is not to say that thepatient would not be upset if she found out such disclosure wasgoing on.”

Professional responsibilityWould limited risk of disclosure be enough to protect a doctorwriting about a case or asking for advice from colleagues online?“No,” Mr Busuttil says. “The fact that the doctor seems in agenuine way to be seeking advice from other doctors mightsupport a public interest defence. Objectively it reads like acanteen-type of conversation where the doctor is genuinelytrying to get a second opinion. And there is of course a publicinterest—trying to improve care—in that, and that can providea defence in law to a claim for breach of confidence or misuse

margaret@margaretmccartney.com

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of private information. However, the doctor in posting thismaterial online is—but may not realise that he is—acting as adata controller for the purposes of the Data Protection Act1998.”The act covers personal data relating to an individual who canbe identified either from that data or from other informationheld by the data controller. The Department of Health says thatthis includes “any expression of opinion about the individual.”9The handling of such data must be consistent with duties ofconfidentiality to the patient if the “processing” is to be lawful.Health professionals who do not comply with the act can besued for damages and have to pay the costs of the claim.There are many medical, nursing, and paramedical blogs thatoffer anonymous insights into frontline NHS care—is this safer?Mr Busuttil doesn’t think so. “If someone has an issue withwhat an anonymous poster or blogger is writing, whether thatperson is a doctor or not, it’s relatively easy to get an order fromthe court against the host of a website or even Twitter requiringthem to identify the person in question. My advice is that it’sill advised for a doctor to blog anonymously as it may encourageeven greater disinhibition.”The hinterland between personal and professional is raised inissues such as “friending” patients on Facebook. This has beendiscussed by the BMA,which recommends doctors do not accept“friend” requests from current or former patients. It also reportsan instance of a patient attempting to make unwanted socialcontact with a doctor. The BMA acknowledges that manydoctors may choose to share some personal information withpatients, but this can be controlled in the consulting room in away that is not possible online.8 The American MedicalAssociation suggests that doctors should separate professionaland personal content online and “must recognize that actionsonline and content postedmay negatively affect their reputationsamong patients and colleagues, may have consequences for theirmedical careers (particularly for physicians-in-training andmedical students), and can undermine public trust in the medicalprofession.”10

Private distinctionsSo does a doctor have to adhere to professional responsibilitiesand standards online at all times—even if communicating onlyto friends or family? Can a doctor act as a private individualonline when not at work? A police inspector was turned downfor promotion after his employers decided that hiscolourful—but legal—descriptions of his private life could“bring the force into disrepute.”11 Is this fair—and what kind ofonline presence can doctors ethically have?The GMC ran an online poll in 2011 asking if it “should regulatedoctors’ lives outside medicine.” Of the 1167 respondents, 1100(94%) said that it should not. In response, the GMC quotedGood Medical Practice, which states: “You must make surethat your conduct at all times justifies your patients’ trust in youand the public’s trust in the profession.” It went on, “Mostcommonly fitness to practise cases citing this paragraph arisewhere doctors are convicted of criminal offences, accept cautionsor equivalent sanctions across the UK. But occasionally we alsotake action on doctors’ registration as a result of doctors’behaviour in the public sphere, which while not illegal, mayundermine patients’ or public trust in the profession. Therationale for this has always been that patients need to trust theirdoctors absolutely. Many patients will be vulnerable when theyseek medical care and need to be able to trust doctorsimplicitly.”12

Asked to clarify the demarcations between the personal and theprofessional, Niall Dickson, the chief executive of the GMC,said in a statement that “Doctors must make sure that theirconduct at all times justifies their patients’ trust in them and thepublic’s trust in the profession. Doctors who comment in thepublic domain about their work or the provision of healthcaremust be mindful of patient confidentiality and treat colleagueswith respect.Wewant to provide helpful advice to the professionso we will shortly be asking doctors and patients for their viewson new draft guidance on the use of social media.” The GMCconfirmed that it has already investigated complaints aboutdoctors’ online activity and expects to do so again. What is lessclear is where a line can be drawn around a doctor’s ability tointeract with others as a normal citizen rather than withprofessional responsibility—the types of activity that may leadto patients not “trusting doctors implicitly” will vary from personto person.Roger Smith is director of JUSTICE, a law reform charityconcerned with human rights. He thinks there is a balance to bestruck. “Do I care as a patient that my doctor is so infuriated bypoliticians that he discusses them with rude language? No.”European citizens are protected under the European HumanRights law, which allows for people to have private lives.“Article 8 of the European Convention on Human Rights givesyou the right to privacy, but there are exceptions. It’s legitimatefor the GMC to be concerned with the trust of the patient, butthere would have to be a link between the personal behaviourof a doctor and the potential to lose the trust,” says Mr Smith,“The doctors’ act under question should be linked to theconsequence and the relevance of it for the patient. In addition,if someone is going to be deprived of their livelihood, thepunishment would have to be proportionate. There probably isno alternative but to say this has to be considered on a case bycase basis. For example, take an online nude photograph. Well,there’s nudity and there’s nudity—by itself it wouldn’tnecessarily be a problem. It would depend how lewd itwas—there’s a difference between japes and, say, objectionablephotographs of genitals that could be really offensive to patients.It would also be dependent on how far they were circulatedround the public. And then, a successful action against a doctorwould depend on the line of causation—could the photoforeseeably lead to a loss of patient trust?”Mr Busuttil also cautions about the liberal use of online mediamore broadly. “Quite a lot of people, not just doctors, have beencaught out by posting online—for example, on Facebook—material deemed by others, especially employers, to beinappropriate. People tend to think of what they post onFacebook as purely their own private business and not to dowith their professional life. But in the real world suchdistinctions can’t be drawn quite so easily, andemployers—rightly or wrongly—may regard something theiremployee has posted on Facebook as completely inappropriate.”But we must not be overly cautious and miss the richness ofcommunication and interaction that social media can offer.Doctors, like other citizens, are entitled to express opinionsonline, and one effect of the undoing of the medicalgod-complex has been to humanise medicine and populate itwith doctors who are fallible but professional. The GMC’s newguidance should reflect the changing, more mature role ofdoctors in society.

Competing interests: The author has completed the ICJME unifieddeclaration from at www.icmje.org/coi_disclosure.pdf (available onrequest from her) and declares no support from any organisation forthe submitted work; no financial relationships with any organisation that

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might have an interest in the submitted work in the previous three years;and no other relationships or activities that could appear to haveinfluenced the submitted work.Provenance and peer review: Commissioned; not externally peerreviewed.

1 Police sacked for Facebook posts.Guardian 2011 Dec 30. www.guardian.co.uk/uk/2011/dec/30/police-sacked-facebook-posts?newsfeed=true.

2 Nurse sacked for remarks about colleague online. STV 2011 Dec 7. http://news.stv.tv/scotland/west-central/214609-nurse-sacked-for-remarks-about-colleague-online/.

3 Nurse’s breasts prompts hospital Facebook ban. www.metro.co.uk/news/336704-nurses-breasts-prompts-hospital-facebook-ban.

4 Nurse sacked over Facebook patient picture. Nursing Times 2011 Nov 2. www.nursingtimes.net/nursing-practice/clinical-specialisms/management/nurse-sacked-over-facebook-patient-picture/5037400.article.

5 Four nursing students expelled from university after posting pictures of themselves posingwith a human placenta on Facebook. Daily Mail 2011 Jan 3. www.dailymail.co.uk/news/article-1343628/4-nursing-students-expelled-posting-Facebook-human-placenta-pictures.html#ixzz1jo1Y42vr.

6 Swedish nurse put surgery photos on Facebook.USA Today 2008 11 Aug. www.usatoday.com/news/world/2008-08-11-3742971419_x.htm.

7 Junior doctor suspended over online comments about professor. Press and Journal 2008Sep 6. www.pressandjournal.co.uk/Article.aspx/825541.

8 BMA. Using social media. 2011. www.bma.org.uk/images/socialmediaguidancemay2011_tcm41-206859.pdf.

9 Data Protection Act 1988. www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Recordsmanagement/DH_4000489.

10 American Medical Association. Professionalism in the Use of Social Media. 2011. www.ama-assn.org/ama/pub/meeting/professionalism-social-media.shtml.

11 Gay senior policeman is denied promotion ‘after revealing graphic details of personal lifeon Facebook. Daily Mail 2008 Feb 28. www.dailymail.co.uk/news/article-521888/Gay-senior-policeman-denied-promotion-revealing-graphic-details-personal-life-Facebook.html.

12 GMC. Your feedback: do you think the GMC should regulate doctors’ lives outsidemedicine? www.gmc-uk.org/guidance/10776.asp.

Cite this as: BMJ 2010;341:e440© BMJ Publishing Group Ltd 2012

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