Canadians are seeing an increasing growth in misinformation about health and healthcare online and on social media at exactly the same time as many are losing access to their most trusted source of information on these topics – family physicians.
Attitudes towards misinformation about health was the focus of newly initiated annual survey commissioned the Canadian Medical Association (CMA) on the Health and Media, results of which were just released. These results and virtual webinar discussing the results came just days after the World Medical Association held a virtual panel on the topic of disinformation in health care.
The CMA survey of 2500 adult Canadians conducted by Abacus Data in September, 2023 found that the majority of English respondents (57%) reported having often come across health and health system information that they later found to be false or misleading.
The CMA survey found generational differences in responses, with younger respondents being more likely to use social media platforms to access health news and information. However, only about 20% of those polled said they trust these social media sources to provide accurate information.
In addition, the survey also found that 72% of Canadians believe health-related misinformation is here to stay and is in fact getting worse. And 40% of those polled said such misinformation has led to anxiety or mental distress.
At a time when millions of Canadians no longer have access to a family physician it is concerning that the CMA survey confirmed that physicians are their most trusted source of health information – followed closely by nurses and pharmacists.
Misinformation and social media have been a focus of the CMA since the presidency of Dr. Katharine Smart in 2021-2022. She made the explicit link between the current shortage in family physicians and the impact this had on Canadians being able to access to a trusted source of medical information.
In a podcast in 2021 she stated: “We have assumed that Canadians have access to a trusted source of medical information to make their health decisions. But more and more, that’s not the case. Over 5 million Canadians don’t have access to a family care physician, which has always been that foundational relationship that people have had and that source of trusted health information.” She went on to say this declining access to experts had been coupled with an increasing access to information which, on social media, is often poor.
In this and other presentations, Dr. Smart talked about the need to reimagine the role of physicians and “stepping up” to share accurate health information online and counterbalance misinformation.
At a virtual session to discuss the current CMA poll, current CMA President Dr. Kathleen Ross reiterated the need for physicians to take a more prominent role in promoting accurate health information in online discussions and on social media. She and journalist Wency Leung, who was also part of the session, also said those promoting accurate health information online or on social media should have their voices amplified by the media and other sources.
Misinformation was also the focus of a session held at the CMA Summit last year and featuring Tim Caulfield, Canada Research Chair in Health Law and Policy and arguably one of the country’s most pro-science advocates. Caulfield talked about the politicization of health misinformation, the fact this false information was resulting in people dying, and the need for physicians to take a prominent role in promoting accurate information.
The CMA is taking an explicit role in promoting accurate health information with the launch of CMA Media in 2022. In addition to funding health reporting positions at Canadian Press to promote more accurate health reporting, CMA Media also plans to develop new and innovative ways to connect online with the younger audience singled out in the recent polling results.
Messaging from the CMA and WMA was mirrored in an opinion piece published by a pair of physicians from the Netherlands in the BMJ last August. Drs. Leonard Hofstra and Diederik Gommers argued that “orchestrated social media action organised by doctors, in collaboration with media specialists, can be highly effective at countering misinformation” – a point also made by Dr. Ross.
Despite the growing toxic nature of some social media platforms such as X, Drs. Hofstra and Gommers noted “staying focused on medical aspects, instead of commenting on political issues, increased our impact and helped keep us out of trouble (such as direct threats) while using social media.”
The CMA survey findings are in keeping with a more general survey done by Statistics Canada and reported at the end of last year which showed that 59% of Canadians said they were very or extremely concerned about any type of misinformation online, and 43% felt it was getting harder to determine what was true online compared with three years earlier.
An earlier Statistics Canada survey conducted during the early phase of the COVID-19 pandemic in July 2020, found that 90% of Canadians used online sources for information about COVID-19 and 96% of these saw information online that they thought was misleading, false or inaccurate. Just over half (53%) said they shared this online COVID-19 information without knowing whether it was accurate or not.
Gather around and warm yourself by the glimmering sparks of evidence-based science in the ruined infrastructure of the platform previously known as Twitter as we provide the 2023 version of the professional use of social media by physicians and in medical education.
Well, things might not be quite that bad, but for the first time in 11 years of speaking to first year medical students at uOttawa I was not telling them that use of social media can definitely be of benefit to them professionally and that the platform previously known as Twitter is their best option.
To quote Mark Carrigan, a lecturer at the University of Manchester: “I believe Twitter can now be a dangerous place for many academics, particularly if they are from minoritized groups.”
While some of us have been hanging on grimly to our presence on X (the platform previously known as Twitter), hoping the situation will change for the better rather than continue to get constantly worse, many prominent physicians, patient advocates and others have fled X for other platforms such as Mastodon or threads. And things seem to be getting worse.
Earlier this week, moderators of one of the only remaining compelling and inclusive medical and healthcare tweetchats #hcldr announced that it would be winding down. Medical and health tweetchats of distinction have been discontinued but in this case the situation seemed sadder. As one of the #hcldr co-hosts Joe Babaian (along with Colin Hung) wrote in a blog announcing the move: “We all know what a hugely different place Twitter is … The vehicle is damaged.”
In my presentation to uOttawa students I discussed the many ways Twitter (now X) has declined over the last couple of years and how many alternatives have arisen in an attempt to replace it. However, as others have pointed out these alternatives have not successfully filled the void for those interested in medicine or healthcare, especially academics.
“We’re in a situation now where it’s not clear that any of the alternatives (to Twitter) will become the alternative. We’re entering a more fragmented landscape where the path to visibility and promotion is going to involve maintaining a presence across a whole range of platforms,” Carrigan wrote, adding that this will require a relatively sophisticated understanding of the platforms and a strategy for using scheduling software. “Any lingering sense of Twitter as a democratising space where academic hierarchies can be levelled, further falls apart under those conditions.”
His views were echoed more forcefully by Professor Inger Mewburn, director of researcher development at The Australian National University who wrote a blog titled: The enshittification of academic social media.
“Telling academics they can achieve career success by using today’s algorithmic-driven platforms is like telling Millennials they could afford to buy a house by eating less avocado on toast,” he wrote in the July 10 blog. “It’s a cruel lie because social media is a shit way to share your work now. Basically, it’s no longer true that you can build a substantial audience by doing Good Work and telling people about it. Today you can talk about your research on social media platforms all you want, but hardly anyone will hear you unless you pay cash money because Algorithms.
Mewburn closed his blog with tips for academics and students and some of these aren’t half bad such as noting social media can be social and a good place to have fun and chat with people and that you should always “own” your own content rather than just produce it on social media platforms. He also urged teachers not to use social media as tools in their classrooms as it may exposure students to the toxic elements that now seem to define much of the social media landscape.
In the face of all of this doom many continue to maintain that X and social media platforms are in general are vitally important places for physicians and others to maintain a presence if only to challenge the politically motivated misinformation about medical and health issues that continues to cost people lives. As Dr. Teresa Chan, the inaugural dean of the medical school at Metropolitan University in Toronto told me earlier this summer: We need to be on social media because the world is on social media. We have to learn to fight misinformation – not be part of it!”
Tim Caulfield, Canada Research Chair in Health Law and Policy and a leading debunker of health misinformation had a similar message for those attending the Canadian Medical Association Health Summit in Ottawa in August. After tracing the leading role social media has had in spreading life threatening falsehoods, he told physicians they had a critical role to play in challenging this information.
X may now be a lousy place to network with your colleagues and associates and grow academic credibility by sharing links to your studies. But if you are of an altruistic bent and believe that advocating for science-based knowledge is important it might be worth hanging in there until the entire platform shatters under mismanagement or falls off a flat earth.
In this Canadian summer of choking forest fire smoke and unnaturally violent storms, it should come as no surprise that apocalyptic cries about the end of Twitter as a viable platform for discourse about healthcare and medicine should once again be heard loudly.
Since Twitter was purchased by Elon Musk last fall there have been repeated dire predictions about how the platform is no longer useful or trustworthy for physicans, patients or anyone wanting a reliable source of healthcare information and/or the learned exchange of views.
In a blog posted at the end of last year, I detailed all the turmoil being experienced by Twitter at the time and noted that “it is clear the uncertainty and confusion around Twitter will continue and probably for some time.” Such has been the case.
The past weekend saw Musk both limit the number of tweets that could be viewed by unaccredited users and an announcement that the invaluable free Twitter management tool, Tweet deck was both being reconfigured (badly in the eyes of many users) and will soon be restricted to paid subscribers only.
Over the spring, it has been clear some Canadian physicians have stopped using Twitter to keep themselves informed about healthcare news and also to inform others about medical developments or their views on healthcare issues. Live tweeting of medical conferences and events has become very much a hit and miss venture with some meetings still seeing strong participation while others are supported by just a single live Tweeter (I know as I have been that person). In addition, many report that a changed Twitter paradigm has made it harder to get one’s tweets seen or to see the tweets of those you are interested in.
The decline in the value of Twitter has been paralleled by a growing interest in other social media platforms that could take its place. Mastadon saw an explosive growth in membership in the immediate wake of the Musk purchase which appeared to taper off rapidly in the spring as users found the platform did not mimic the Twitter experience. In the wake of the rate limiting announcement by Musk, Mastadon once again seems to be coming to life. It was also announced this week that Meta will launch Threads, a “text-based conversation app” linked to Instagram to rival Twitter. This is ironic given that at the same time Meta has said it will restrict access to Canadian news sources on Facebook and Instagram to protest recent Canadian legislation.
But to many physicians it seems Twitter still matters. A study of US physician Twitter use finds that the profession continues to rely on the platform. An analysis reported by Greg Mathews, CEO of HealthQuant showed that the numbers using Twitter remained about the same between the third quarter of 2021 and the second quarter of 2023. “For now, at least, twitter continues to be THE platform where doctors are engaging,” he said.
As someone who follows what physicians are doing and saying and tries to curate information for the profession and their patients the message is clear. Until Twitter goes totally dark – in a real or a metaphorical sense – I will still be there too.
A physician’s reputation is one of their most important and prized assets.
The advent of the Internet and social media have produced a vastly increased scope for physicians to increase their reputations. To quote Texas pediatrician Dr. Bryan Vartabedian, “the democratization of media has made every physician an independent publisher …physicians now have to learn to manage and maintain their identity in the public space.”
While social media has produced huge opportunities for enhancing reputations, at the same time it has created a whole new set of challenges and threats to how physicians are seen by prospective patients, their communities, and others. This would explain why the College of Physicians and Surgeons of Alberta (CPSA) has chosen to allot such a large segment of its updated advisory to physicians on social media to the topic.
In the document released in August which updates earlier advice from 2014, the CPSA notes that “recent studies show that up to 50% and that being impersonated online in a negative manner can have devastating consequences, both personally and professionally.”
The College goes on to provide a list of tips on how physicians can protect themselves against such fraudulent accounts. These include:
Providing a detailed professional biography in their social media profile
Checking comments and messages daily (emphasis mine) to see if fraudulent activity has been noted by contacts
Checking security settings to ensure your posts and account information are only visible to the people who you want to see them.
Enabling two-factor authentication on accounts
Not linking your social media accounts so posts from one account automatically post on another account
Using secure passwords
The College also provides advice on what to do if you think your account has been taken over and goes as far as to provide an example of suggested wording of what to post to your legitimate social media accounts if you have been a victim of a fraudulent account.
All of this is sound advice, but it demonstrates how the various physician regulatory Colleges across the country have taken very different approaches to what they choose to emphasize when talking about social media. The Alberta College renewed guidance comes at about same time that the College of Physicians and Surgeons of Ontario also published revised guidelines on social media. The new CPSO guidelines make no reference to fraudulent accounts choosing rather to emphasize the need to publish only evidence-based materials (However both Alberta and Ontario as well as regulatory bodies in other jurisdictions stress the need for physicians to act professionally and protect patient confidentiality if they speak to the social media at all – and some still do not).
Oh, if you are concerned about having your own accounts hijacked or in checking your online reputation Googling yourself regularly to see how you are portrayed online is a tried and true method of doing so.
Every year for the last decade I have been privileged to give an orientation lecture to first year medical students at uOttawa about the professional use of social media for physicians. The following is a long blog post but severely abridged version of this year’s lecture.
This year’s presentation focused on two key themes:
The social media world has evolved incredibly in the decade that physicians have been using the platforms professionally
The principles for using social media professionally have not really changed at all
Nothing demonstrates the first point better than the stark change between 2013 – when physicians and medical learners were urged to get on social media and try it out because they were smart people who would quickly learn the ropes – and 2022 when physicians must have a good understanding of social media in order to use the platforms safely.
To use a preaching analogy, this year’s lecture was built around two key texts:
New guidelines on the use of social media for physicians published by the College of Physicians and Surgeons of Ontario (CSPO) in June of this year.
This new guidance is particularly important because it represents the pre-eminent guidance physicians in Ontario must follow if they want to avoid charges of professional misconduct
The guidance reflects the realities of practice in 2022 as the CSPO has been diligent in keeping up with the times.
Remarks made by Dr. Katharine Smart, a Yukon pediatrician who until recently president of the Canadian Medical Association.
In key quotes that follow, Dr. Smart lays out the rationale for why physicians must use social media channels to advocate for evidence-based care. The quotes are from a podcast interview given by Dr. Smart this summer to the CHA Learning – the educational arm of HealthcareCAN – the organization representing Canada’s healthcare institutions.
Dr. Katharine Smart
“We have assumed that Canadians have access to a trusted source of medical information to make their health decisions. But more and more, that’s not the case. Over 5 million Canadians don’t have access to a family care physician, which has always been that source of trusted health information. In parallel we’ve had this evolution of that social media environment where so many people now are going to get information. So we’ve got declining access to experts (but) increasing access to information and we know that on social media health information is often poor. A recent study showed that 87% of posts about health on social media contain some sort of misinformation. We have to reimagine ourselves a bit as physicians and what our role is in terms of stepping into the public to share information and to counterbalance misinformation, in an effort to improve the health of the public as a whole and communities.”
We’ve got to be on spaces like TicTok, Twitter, Instagram, where a lot more people are interacting, and package our information differently for different ages and different segments of the population.
When you’re in public spaces, and people know you’re a physician, you are representing the profession, whether you want to be or not. It’s just part of what goes along with the privilege of something like being a physician.”
Dr. Smart also makes the points that social media is not for all physicians but those who choose to use the platforms need the appropriate education to do so – something that is often lacking at the medical learner stage. She also talks about how useful social media has been for her in networking with her peers.
Dr. Smart’s comments are mirrored by the new emphasis that the CPSO guidelines place on physicians only sharing information on social media that is evidence-based. This new emphasis comes directly as a result of the COVID-19 pandemic and the proliferation of non-scientific views by some physicians.
Why consider using social media or social networks professionally as a medical student or physician?
Social networking is a key component of the digital world where physicians now have to practice. To quote Dr. Bertalan Mesko, a Hungarian physician and leading futurist, from a few years ago: “Today’s medical professionals must be masters of different skills that are related to using digital devices or online solutions and mastering those skills is now a crucial skill set that all medical professionals require.” Changes forced upon medical practice by the pandemic have made this even more important.
I believe part of what Dr. Stern is referring to is the fact that patients use social media extensively to talk about medical matters in general or even their own health. Broader conversations about health policy are also happening there. This has been particularly true since the pandemic.
So, arguably to understand or to participate in those conversations you need a social media presence.
I list here what I believe to be the key ways in which medical learners and physicians can use social media to stay informed
Follow selective media outlets who often post news first on social media channels before more traditional outlets.
Follow trusted individuals who curate useful medical information and provide links to original sources.
Monitor selected journal releases in a timely fashion.
Up to date clinical information can be obtained following medical conference hashtags. The recent European cardiology conference #ESCCongress is a great example of this.
Interact with experts
Monitor important conversations around medical issues – everything from masks in the pandemic to proper airway management
Social media is not only a great way of networking with peers, colleagues, experts and patient advocates but social media channels can also be a powerful way of building alliances. Through networking and use of social media women physicians and racialized physicians have become far more empowered and they have used their social networks for support when challenged by others.
Social media can also be a powerful means of providing inspiration and just provide “feel good” moments at a time when the medical profession needs this more than ever.
Social media is IRL and more and more physicians and others are sharing their lives – not just with friends on Facebook but even in the world on Twitter and LinkedIn.
They’re sharing life changing events in their lives on Twitter. Births, deaths, breakups and breakdowns. They are also sharing what they see and feel and this has been particularly event in relation to COVID-19.
I would argue this is part of a bigger picture. The role of physicians in society is changing – as is the way the medical profession views its own commitment to society.
Unlike a decade ago physicians often maintained separate existences on social media with different accounts for their personal and professional lives – now more and more they are merging the two. The CPSO guidance acknowledges this while stressing that physicians should act professionally however they are using social media.
This personalized approach has been indirectly endorsed by a court decision in Saskatchewan Court of Appeal – the province’s highest court, in a case involving a nurse which stated in 2020 that “Nurses, doctors, lawyers and other professionals are also sisters and brothers, and sons and daughters.” Mr. Justice Brian Barrington-Foote went on to say: “They are dancers and athletes, coaches and bloggers, and community and political volunteers. They communicate with friends and others on social media. They have voices in all of these roles. The professional bargain does not require that they fall silent.”
In an interview in 2021, new CMA president Dr. Alika Lafontaine said this sharing by physicians has been powerfully cathartic. “I’ve never heard so many physicians actually share the pain that they go through day after day. I’m both sad, as I hear the stories, and hopeful, because we’re sharing the lived reality of what we’re going through.
The bottom line is that you can maintain and professional presence on social media and interact professionally while also being a human being and sharing – to whatever degree you feel appropriate – your personal life.
I liken it to being a physician in a small community. You care for patients but you also shop in the local grocery store and take your kids to soccer practice.
The whole issue of whether physicians should maintain two separate personal and professional accounts on social media arises here as well. Two Canadian physicians Drs, Blair Bigham and Sarah Fraser addressed it in a blog post on the BMJ Opinion site. They state physicians should “embrace authenticity and reunite their personal and professional selves. In times like these, we must … make a therapeutic relationship with the public to advocate effectively, and the work of advocacy requires revealing our true selves.”
For every why there is a why not. Ten years ago I didn’t dwell on this but the world has changed and social media have become far more malignant and risky for physicians to use.
Social media has become an ugly, nasty place inhabited by trolls, spamBots and others It can make physicians feel unwelcome and unsafe. There are also any instances in last few years where physician camaraderie has broken down and pitched doctors against each other especially along seniority and gender lines. This has helped highlight fundamental inequities that continue to exist within the practice of medicine.
It takes a certain fortitude and outlook to be able to advocate strongly on social media about divisive issues and it’s not for everyone. It’s impossible to have heated but constructive discussions within the confines of Twitter or other limited social media channels. And the abuse has caused some physicians to abandon Twitter for the relative professional safety of LinkedIn or just to retreat to their small personal social circles on Facebook.
Physicians who plan to use social to promote social causes need to be prepared for abuse that far exceeds what we consider acceptable.
Advice on how physicians should respond to harassment on social media must now, unfortunately, become part of any educational exercise. The following tips come from Dr. Najma Ahmed, a Toronto trauma surgeon and founder of Canadian Doctors for Protection From Guns.
Over the years I have reworded and whittled down advice on how medical learners and physicians can and should use social media professionally, but the advice has remained the same.
Respecting patient confidentiality remains the number one tenet of this advice. Never post anything that will identify a patient unless they very clearly and explicitly request it.
The CSPO and other physician regulatory bodies wants physicians to act on social media in a way that won’t damage the reputation of the profession. On the other hand we have many physicians, especially women, pushing back against the idea that professionalism means being well-dressed, well-behaved, polite, and deferential to authority.
This may be best represented by the hashtag #MedBikini movement which emerged a couple of years ago. Leading social media commentator and pediatric gastroenterologist Dr Bryan Vartabedian blogged about the issue and I quote him at length here:
“A study published in the Journal of Vascular Surgery line itemed the apparent transgressions of a group of surgical trainees. The study, Prevalence of unprofessional social media content among young vascular surgeons, cited breaches of professionalism including wearing swimwear (medbikini), drinking alcohol, profanity and commenting on controversial social topics. Their criteria for unprofessional were based on previously published studies from as recent as 2017. As news got out medtwitter had its own 2020 cancel culture moment under the hashtag MedBikini with thousands of tweets showcasing the unprofessional elements identified in the study. Then bending to post-publication review, the study was retracted on the basis of its methodology and concerns for bias. The faulty foundation of this paper is its failure to understand the standards of medicine’s digital culture. The assumptions about alcohol, bathing suits, language and the public discussion of controversial subjects reflect dated standards about how doctors engage and communicate in a global community. And so this paper is something I might have seen a decade ago when the medical world was petrified that Twitter might be used to share pictures of doctors in bikinis. Times, of course, have changed.”
Dr. Jessica Pearce, an ob/gyn had a more blunt take in a different blog post at the same time:
“Our bodies may have tattoos, ride motorcycles, or compete in pole fitness competitions for sport. None of that impacts our practice of medicine negatively. It’s past time we start celebrating the strength of our bodies and hold accountable those who try to negate our accomplishments with an ill-perceived attitude of sexism and misogyny.”
I closed the 2022 lecture with a quick overview of what I see as current trends relevant to the use of social media by physicians.
Social media channels continue to provide a valuable resource for medical learners and physicians who choose to make use of them.
But more so than ever in 2022, physicians must take the time and make the effort to use these channels in ways in which they are comfortable and feel safe. And more so than ever, they need the education to do this safely.
(A caveat: This presentation was built for an audience of medical learners. As such it does not stress the critical role social media channels have played in helping patients and caregivers also build communities and information channels to strengthen their roles on the health care team)
For the first time, Ontario physicians are being given advice by their regulatory body on how to use social media to support equity diversity and inclusiveness (EDI).
The guidance is contained in a companion document to a new policy on social media published last month by the College of Physicians and Surgeons of Ontario (CSPO). The new policy puts an emphasis on preventing conduct on social media that could harm the public’s trust in individual physicians and the profession especially the publication of misinformation.
The updated CPSO policy and companion materials show the regulatory body continues to keep pace with the current social media environment and also drops what I saw as some of the more controversial aspects that were contained in draft materials published a year ago as detailed in an earlier blog post. The reference to physicians swearing on social media as an example of disruptive behavior has been dropped. Also dropped is advice for physicians to maintain separate professional and personal accounts.
The new CPSO policy stresses the need for physicians to act professionally on social media by not posting misinformation and only posting information that is “verifiable and supported by available evidence and science.” The policy also acknowledges the important role physicians have in advocacy and states “while advocacy may sometimes lead to disagreement or conflict with others, physicians must continue to conduct themselves in a professional manner while using social media for advocacy.”
The new policy places an emphasis on protecting patient information and not sharing individual patient information without very clear, explicit consent from the patient. The policy also states physicians must refrain from seeking out a patient’s health information online without patient consent. However, the policy details several exceptions including if the information is necessary for providing health care or if accurate or complete information cannot be obtained from the patient and obtained in a timely manner.
The new section on EDI states “It is also important for physicians to be aware that their conduct on social media (including liking, sharing, or commenting on other content) may be visible to others and that unprofessional comments and behaviour (which can be overt, or more subtle, like microaggressions) have the potential to make others feel marginalized and impact their feelings of safety and trust, and potentially impact patients’ willingness to access care.” The section references cultural safety and humility and says the CPSO supports physicians “striving to foster” an inclusive environment.
The advisory document notes physicians may choose to keep professional and personal accounts on social media but acknowledges the professional and personal are not always easily separated and says it is important that physicians act professionally in both contexts.
In addition to the specific reference to advocacy in the new policy, the CSPO also addresses this at more length in the companion document. For example, it notes that “if you practise in an institutional setting, you may be subject to their policies or guidelines around social media use. Some institutions may require express permission before engaging in advocacy activities on social media that could be interpreted as directly involving them.” When advocacy efforts on social media could impair a physician’s ability to deliver quality care or collaborate with others, the CPSO says the physician should consider whether their advocacy activities “are in fact in the best interests of patients and the public.”
The College also recognizes physicians can experiencing personal attacks or harassment online due to their advocacy activities and supplies a link to a list of health and wellness resources as well as urging physicians to be aware of privacy controls and reporting mechanisms they can use.
Widespread dissemination of misinformation about healthcare on social media is threatening the capacity of Canadians to transform and improve how healthcare is delivered.
That is why Canadian physicians have an obligation and not an option to be active on social media platforms.
This statement was made by Canadian Medical Association (@CMA_Docs) President Dr. Katharine Smart (@KatharineSmart) at the Canadian Conference on Physician Leaders held recently in-person in Toronto. It represents one of the most high profile and strongest statements supporting physician involvement on social media made to date in Canada.
It was probably no coincidence that the #CCPL2022 hashtag was used extensively by physicians and others throughout the two-day meeting – and beyond – with both those in attendance and many others remotely commenting on and retweeting proceedings.
In her address, Dr. Smart singled out as an emerging threat to healthcare “the ineffectiveness of traditional communication tactics in a social media world, the rising threat of misinformation, a loss of trust with experts, and increasing polarization even amongst experts themselves.” She added “I think these issues threaten not only health, but pose fundamental threats to our democracy and civil discourse.”
Dr. Smart asked how physician leaders and physician organizations can compete in this new environment. “Our traditional press conferences are really no match for a well done Tiktoc video or Instagram story. Social media has become the source of information and truth for many people, youth and adults.”
“One of the lessons we’ve learned through the pandemic has been around the critical role of health communication, how much we struggled to do well, and how powerful the misinformation movement can be,” she continued.
“I think we need to recognise that social media is where we’ve evolved in terms of our community gatherings or town halls and how we distribute information and communicate with each other. If we don’t evolve and show a presence on social media to educate and impart our knowledge about health, medicine, science to the public, and even things about the health system itself, other less qualified non medical individuals will.” Dr. Smart said the CMA has made a conscious effort as part of its modernization process to become more involved and engaged on social media and has a result garners millions of impressions monly across its social media platforms.
However, with more physicians and other healthcare providers speaking out and advocating on social media, Dr. Smart acknowledged the number of personal attacks and abuse has risen. At the CCPL last year, past CMA president Dr. Gigi Osler and gun control advocate Dr. Najma Ahmed gave a workshop on just how to deal with this abuse.
Dr. Smart showed a word map demonstrating it is the most emotive words on Twitter that create the most engagement. “I believe that this is driving polarization and can negatively impact information sharing and discourse. People that are yelling are often getting the most attention and the people that actually have productive things to say … don’t always stand out in these spaces.”
She told physicians that “angry advocacy” is not the way to go and that physicians must work to counter the current “infodemic” that “threatens to disrupt and undermine our work.”
The College of Physicians and Surgeons of Ontario (@cpso_ca) has published its new draft policy statement on the use of social media by physicians and, I fear, if implemented as written it could have a chilling effect on how physicians represent themselves. In proposing strong new language to enforce professional behavior when using social media, the CPSO risks alienating many of its members and could see doctors in Ontario abandon social media platforms to which they contribute so much.
It’s a fine line because many of the changes proposed are being done for the right reasons to discourage the posting of health information that is not evidence- and science-based and to discourage posts that could be described as harassing, bullying or discriminatory. The new draft can also be applauded for containing a preamble discussing how physician professionalism supports equity, diversity and inclusiveness and also includes specific acknowledgment of the importance of advocacy.
The CPSO has always been in the forefront among Canadian regulatory authorities in considering the impact of social media on physicians and their patients. The current policy statement dates from 2013 and was opened for revisions last year as I noted in a blog at the time. The impact of the policies cannot be overstated because contravening them can leave physician open to charges of professional misconduct.
As noted in a document for its June Council meeting, 366 responses were received from the external consultation on the new draft document with the majority of these coming from physicians. This briefing document also noted that since the original 2013 statement “social media use among physicians has increased significantly and presents new risks and challenges for physicians to navigate …”
Many of the proposed changes are aimed at addressing concern about the current statement being too vague in defining unprofessional behavior by physicians on social media. The council briefing note also explains that the draft policy includes new requirements around disseminating general health information, recognizing the concerning spread of misinformation on social media in past years (e.g. anti-vaccination views, misinformation related to COVID-19).
The new policy statement has a lot of “must and must nots” that were lacking in the current statement, such as:
Physicians must conduct themselves in a respectful and professional manner while using social media
Physicians must consider the potential impact of their conduct on their own reputation, the reputation of the profession(emphasis mine), and the public trust
Physicians must not engage in disruptive behavior … including use of profane language (i.e. no more swearing)
The new draft policy hits all the right buttons linking physician professionalism with values such as altruism and cultural humility. But one wonders how this new statement will be interpreted by those who see strong-handed enforcement of professionalism as maintenance of the traditional, parochial approach to medicine that runs so counter to the outlook of the many women physicians who have taken to social media to advocate for more gender equality.
The statement about not sullying the reputation of the profession on social media also raises a big red flag as we have seen how another health profession in Canada unsuccessfully tried to use this to stop an individual from voicing legitimate concerns on social media about the delivery of care.
As with the existing policy, the new policy also deals with the area of professional relationships and boundaries stressing that physicians “must” maintain professional boundaries with patients, persons closely associated with patients, and colleagues while using social media. While the existing document has an end-note saying some physicians may choose to do this by maintaining separate online presence for personal and professional networks, the guidance document for physicians about the draft policy is more forthright in stating “having a separate professional account can help you maintain appropriate boundaries on social media.”
This advice seems outdated in an era when physicians are moving to be more well-rounded individuals on social media blending professional and personal interests. Some of the most respected physician social media accounts share personal details and professional views in a compelling manner.
I would argue that in any community, a physician can be themselves with personal interests while at the same time maintaining therapeutic relationships with patients. Some of my favourite Ontario physician Twitter accounts mix strong views on a wide variety of topics with questionable cooking tips, wine reviews, family snapshots and more.
Bifurcating physicians on social media is not the way to go. And has been argued recently by two Canadian physicians, creating this artificial divide could impact the effectiveness of physicians as advocates.
While I believe it is flawed, the new @cpso_ca document is a brave attempt to wrestle with defining how physicians should be using social media in 2021 – a world that has changed profoundly since the guidance of 2013.
Those interested have until the end of August to comment on the new draft statement. Given how much there is to unpack in this new important document – beyond what has been discussed in the confines of this current blog – I would urge reading the new draft policy and background document here.
(The following summarizes part of a presentation given April 29 at the Canadian Conference on Physician Leadership with Drs. Najma Ahmed and Gigi Osler)
Nine years ago I gave a presentation to Canadian physician leaders addressing whether it was worth a physician’s time to get involved with social media.
Much has changed over the past decade and now questions revolve around not whether social media can be of professional value to physicians – it obviously can – but rather how physicians can engage on social media safely and for what reason.
Summarizing developments in physician use of social media in recent years, and especially since the onset of the COVID-19 pandemic, I would highlight the following points:
The growth in physician use of social media
The changing landscape of social platforms and development of a more favourable regulatory environment
Growing emphasis on social media for advocacy purposes
Growing personalization of physician social media accounts
Acceptance of social media involvement in academic medicine
Not every Canadian physician – or even the majority – use social media for issues relating to medicine and healthcare but there has been a definite increase over time especially when it comes to Twitter. A poster presented at the virtual International Conference on Physician Health last week by Christian Guerrero and Christopher Khoury from the American Medical Association estimated that at least 100,000 US physicians and medical students use Twitter. Analysis of a cohort of 16,000 of these users found their tweets focused on work/life balance, patients, and socio-political issues.
Twitter, Facebook and LinkedIn have remained the primary platforms of interest for physicians although younger physicians have also taken to Instagram. Arguably not a social media platform, WhatsApp has also become hugely influential for physicians in Europe and other parts of the world for connectivity and offering health related engagement tools. During the decade other social media tools such as Twitter Periscope and Google+ have disappeared from the landscape while others such as TikTok and SnapChat have appeared with more and less impact respectively on the general physician audience.
Interestingly, over time there also seems to have been a shift away from engagement tools such as blogs and tweetchats to podcasts and new audio-based channels – Clubhouse and Twitter Spaces. The almost total transition of medical conferences from in-person to a virtual format during the pandemic has been accompanied with a drop in the use of Twitter exchanges associated with such meetings in favour of use of the chat function on the meeting platform. Virtual platforms to date seem to be having little success in making linkages with social platforms so far to broaden engagement to those not registered for the particular conference.
The changing landscape of social media offerings has been accompanied with a changed regulatory environment for physicians in Canada around their use. A decade ago, provincial physician colleges were ambivalent if not downright hostile towards any physician use of platforms such as Facebook. Over time these regulatory bodies have come to acknowledge that when used appropriately social media platforms can be useful engagement tools for physicians.
One of the biggest shifts in physician use of social media I have noticed over the past decade has been the increasing use of platforms such as Twitter to advocate on various medical, health and social issues.
While physicians have always used social for advocacy there has been a significant increase in this use in recent years especially for issues relating to equity, diversity and inclusion and more recently, to advocate for public health and science-based measures to control the COVID-19 pandemic.
A 2018 article in the New England Journal of Medicine, argued persuasively that the increasing use of social media by physicians could offer women physicians “additional coping mechanisms, provide new avenues for sharing information, and perhaps reduce stigma associated with sexual harassment, burnout and workplace culture.” Popular hashtags such as #IlookLikeASurgeon and #Medbikini and ongoing series of posts concerning the need for gender equity in compensating physicians and support for more women physicians in Canadian medical organizations support this statement.
Similarly growing advocacy efforts by physicians around Black Lives Matter, climate change, and gun control also reflect the trend. When it comes to COVID-19, physician social media use has built on an already strong network of physicians challenging antivaxxers, addressing vaccine hesitancy and calling for the promotion of science-based approaches.
Doctors, nurses and other healthcare providers in Canada may have an understandable concern about speaking out on social media for fear of being reported to their regulatory bodies for unprofessional conduct. However in a Saskatchewan Court of Appeal decision last fall, Mr. Justice Brian Barrington-Foote provided a measure of comfort for those who feel the need to speak out. He stated that “Nurses, doctors and lawyers and other prfessionals are also sisters and brothers and sons and daughters. They are dancers and athletes, coaches and bloggers and communty and political volunteers. They communicate with friends and others on social media. They have a voice in all these roles. The professional bargain does not require that they fall silent.”
In a somewhat related trend, physicians in recent years are tending to share more about their personal lives on social media and public platforms such as Twitter. Canadian physicians, @BlairBigham and @sarahfraserMD argued in a recent BMJ Opinionblog against physicians maintaining separate personal and professional social media accounts. They wrote that physicians should “embrace authenticiy and reunite their personal and professional selves. In times like these, we must … make a therapeutic relationship with the public to advocate effectively, and the work of advocacy requires revealing our true selves.”
Births, deaths and health and well-being issues are shared on an increasing basis by physicians especially since the onset of COVID-19. While not referring specifically to social media, Canadian Medical Association president @AlikaMD recently noted that “I’ve never heard so many physicians actually share the pain that they go through day after day. I’m both sad as I hear the stories and hopeful, because we’re sharing the lived reality of what we’re going through.”
My co-presenters @drgigiosler and @najmadoc make the point that social media platforms are also providing growing informal networks of support for physicians – especially women who are more prone to be targetted for abuse on these platforms.
The other area worth noting in the evolution of physician use of social media has been the growing acceptance of social media in academic medicine. To quote @TchanMD, a leading Canadian researcher on this topic: “Social media is a tool that the modern scholar and scientist should have in their armamentarium. Being engaged in social media can assist you in your academic work by cultivating mentors, raising awareness of your research and scholarship and facilitating scholarly collaborations.”
We are now at the point where scientific papers and even dedicated issues on social media appear regularly in peer-reviewed medical journals and having a physician social media editor has become the norm rather than the exception for these journals. Citation of articles on social platforms are being measured and some institutions have gone as far as considering social media activities when considering career advancement.
Unfortunately this has not be accompanied at Canadian medical schools by much of a focus on educating medical students and residents on how to use social media professionally and safely. As such, students and residents are more prone to run into trouble when using social media platforms despite growing up with the platforms.
I will not dwell on it here but the trends outlined above have been accompanied by the unfortunate reality that use of social media now can make physicians feel both more unwelcome and unsafe than it did in the past. Social media can be an ugly, nasty place inhabited by trolls, spambots and doxxers. To quote my co-presenter, @drgigiosle “social media is dark and full of terrors.”
There have also been numerous instances in Canada where physician cameraderie has broken down and pitched doctors against each other often along seniority or gender lines. Physicians have also sued physicians about social posts.
All of this underlines that fact that while use of social media can be hugely beneficial and satisfying for physicians it can take a certain fortitude and outlook to advocate on social media about divisive issues. – or even apparently non-divisive issues. Whether discussing the right way to intubate a patient or posting your favourite recipe for cookies and sometimes result in the most unexpected and virulent attacks on doctors.
However, one just need look to physicians advocates such as @najmamd and @DrJenGunter or high profile media commentators such as @NightShiftMD to see that these storms can be weathered successfully. A growing community of active physician participants on social media also means a growing number of allies for those who are attacked inappropriately. Blocking and/or reporting threatening individuals and posts can have an impact.
The Twitter of 2021 is not the Twitter of 2012 and the social media realities of the early 2020s will surely continue to evolve and mutate. Canadian doctors as a profession have come a long way in their use of social media in the past decade to the benefit, I would argue, of both themselves and of society.
For years I have lectured new medical students at @uOttawamed that the best physician Twitter accounts reflect the whole personality of the individual. I argue that maintaining separate professional and personal accounts has little benefit, creates a false dichotomy and can dilute your voice.
Even before the COVID-19 pandemic I noted a growing trend for physicians and others to be more willing to share elements of their own personal life on Twitter in additional to their views on issues.
It’s a trend that has not gone unnoticed both on and off social media.
In a recent interview, CMA president-elect Dr. Alika Lafontaine (@AlikaMD) said this sharing by physicians has been powerfully cathartic. “I’ve never heard so many physicians actually share the pain that they go through day after day. I’m both sad, as I hear the stories, and hopeful, because we’re sharing the lived reality of what we’re going through.
“In supporting colleagues across the country, I’d say keep sharing your story. I hear you, I see you, I feel what you’re going through. The other side of that is figuring out how to take these stories and actually have them impact the thoughts and beliefs of decision makers who create the structures that we work in.”
This perspective contrasts somewhat to views voiced by Drs. Eric Topol and Abraham Verghese (@EricTopol and @Cuttingforstone) in a recent discussion at least when it comes to social media. They made the point that Twitter is not well suited to sharing personal narratives, in large part because of the constraints imposed by the 240 character count on tweets. While it is true that books and other long forms of literature can more completely reflect a person’s story, one should never understimate the ability of smart people to create powerful narratives in just a few words.
I would argue that the most compelling physician Twitter accounts for both their peers and the general population manifest the personality of the person doing the posting. Dr. David Naylor and his dog (@CdavidNaylor), Dr. Brian Goldman and his ruminations on the failings (and very occasional triumphs) of Toronto sports clubs (@NightShiftMD), and the baking adventures of countless other physicians during the pandemic, all come to mind.
The whole issue of physicians maintaining separate personal and professional accounts has recently been given attention by two Canadian physicians @BlairBigham and @sarahfraserMD in a blog post on the BMJ Opinion site.
They argue that while many top medical organizations still recommend that physicians maintain separate personal and professional social media accounts, physicians should “embrace authenticity and reunite their personal and professional selves.”
“In times like these, we must … make a therapeutic relationship with the public to advocate effectively, and the work of advocacy requires revealing our true selves,” they write. They say this is particularly important when physicians are advocating on public health issues or advocating for social justice.
Recent research suggests the public is more willing to trust pronouncements from individual physicians than professional organizations on issues relating to COVID-19 and surely trust can only be strengthened when the physician posting can clearly be seen as an individual.
Of course, imbuing your Twitter account with personality entails risk and physicians must think hard about how much they are wiling to share. Many draw the line at posting anything about their family on Twitter and this can confer a degree of security against trolls or worse.
And the call to maintain one Twitter account that reflects your whole personality does not mean you should do the same on many social media platforms. Physicians should consider which platform works best for them and use them. Many keep Facebook purely for close, personal interactions and use LinkedIn only for career-oriented interactions, and that makes perfect sense.
However when it comes to Twitter at least, keeping both a personal and professional account can be done but if you want your voice and opinion to count being the whole you makes a lot of sense. And when it comes to professional behavior, the same rules apply no matter which account identifies you.
Days of Past Futures 