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.
Where better to find a predominately positive overview of the current impact of social media on healthcare than during a #hcldr tweetchat?
Launched in 2012 and masterfully moderated by co-hosts Colin Hung (@colin_hung) and Joe Babaian (@JoeBabaian), #hcldr is one of the only remaining regular weekly tweet chats that deals with a broad range of healthcare topics.
Earlier this week, they hosted a chat on the current state of social media and healthcare that drew almost 200 participants including physicians, other health care providers, digital health specialists, patients and patient advocates predominately from the US but also from Canada, the Philippines and other countries.
From among the usual rapid-fire exchange of greetings and subchats emerged a strongly positive overview (with caveats) of the role of social media in healthcare. It also revealed interesting insights into the continuing evolution of how informed individuals are utilizing these platforms.
Most of those contributing to the chat indicated their use of social media has changed over the years.
Some talked about switching their emphasis from Facebook to Twitter and LinkedIn and from using social media for social interactions to taking a more professional approach and becoming more engaged. While definitely an older cohort of social media users, some participants talked about productively having used Snapchat and now TikTok.
However, Dr. Nick Van Terheyden (@drnic1), a digital healthcare innovator and former chief medical officer for Dell, noted his use of social media has decreased significantly because the platforms have been “weaponized” to promote dissinformation. Ziva Mann (@MannZiva) agreed, adding that now without careful facilitation “venom” often seeps into social media discussions.
For the vast majority of participants, social media today seems to be used primarily for engagement and networking and for information gathering or curation. As Ottawa child psychiatrist Dr. Gail Beck (@gailyentabeck) tweeted: “I access some of the best information on many subjects from social media. I’ve ‘met’ some inspiring people and groups like #hcldr.”
Dr. Rashu Shrestha (@RashuShrestha), chief strategy officer at Atrium Heath, noted “social media has always been about connecting at an exponential scale. The value of @Twitter has evolved from basic information sharing to meaningful engagement, and much deeper dialogue.”
“Every generation will have education and information gaps and “discover” social media as a tool to learn and share more among themselves,” tweeted Dr. Meredith Gould (@meredithgould), an author and digital activist. However she later added “I believe at least one and maybe two generations of physicians and allied health workers need to depart this mortal coil before social media is fully appreciated. Young hc pros on TikTok are delivering essential info with delightful edge.”
In response to one of the tweet chat questions, participants seemed in strong agreement that social media has a role in healthcare today, particularly as a means of patient empowerment.
As Annie-Danielle Grenier (@AdanGrenier), a patient partner in Quebec tweeted, social media can help patients obtain information as well as being a place for support groups. Social media, she said, can also help healthcare professionals get their message out and learn from patients.
“I often tell patients about hashtags or social media groups that I think are good for their specific medical experiences or diagnoses,” confirmed Dr. Latita Abhyankar (@L_Abhyankar), a US family physician, in her tweet.
“While the way we use social media may evolve, it is still a valuable outlet for education, collaboration, and information. It allows us to challenge healthcare norms, advocate for patients, and support our peers,” tweeted Shereese Maynard (@ShereeseMayMba), a digital strategist.
Physicians sharing personal stories on Twitter are seen as being more effective in communicating COVID-19 recommendations than impersonal messages from federal officials. That’s the conclusion of a study just published online by Dr. Rachel Solnick and colleagues based on a randomized experiment conducted with more than 2000 US adults.
This timely study underscores one of the most important points made at the recent Canadian Immunization Conference, namely that physicians and other health care providers are the most effective communicators when it comes to communicating the importance of COVID-19 vaccines.
“You’re abandoning your patients and leaving them open to an incredible amount of disinformation if you don’t get involved on social media,” said Dr. Todd Wolynn, a Pittsburgh pediatrician speaking at the meeting, during a session on countering the anti-vaccination movement. At the session, Dr. Wolynn was accompanied by Dr. Philipp Schmid, a behavioral scientist at the University of Erfurt in Germany who in 2016 literally helped write the book (along with Canadian pediatrician and former dean Dr. Noni MacDonald and others) on publicly responding to vocal vaccine deniers.
This and other sessions at the immunization conference came as public health experts and others plan on how to effectively disseminate vaccines against COVID-19 at a time when COVID-19 deniers and anti-science advocates are running rampant on social media.
The anti-vaccination movement is one of the older and most dangerous of the anti-science movements for its attempts to sway a number of well-meaning parents against life-saving vaccinations for their children. In recent months in Canada I have seen two other examples of physicians coming under virulent personal attacks as a result of their defense of public health initiatives.
The first was at the Canadian Cardiovascular Congress in late-October when I tweeted remarks from Drs. Stanton Glantz and Andrew Pipe on the negative impact of vaping which drew the ire of pro-vapers throughout North America on Twitter that did not subside for more than 24 hours. The second came just days ago when the Canadian Medical Association promoted the award it had given Dr. Najma Ahmed, a trauma surgeon in Toronto, co-founder of Canadian Doctors for Protection from Guns. The tweet from @CMA_Docs prompted days of attacks on Dr. Ahmed, other physician gun-control advocates and the CMA with many attempting once again to apply misdirection by referencing opioid overdoses, medical errors and physician privilege as reasons to discredit physician views.
These two recent incidents demonstrate just what can be involved for physicians who choose to take public health stances on social media that draw the ire of a segment of the social media population that is not afraid to stoop to any tactic to defend their views and discredit the opposition. It also underscores that the fact despite the acknowledged need for physicians to speak up on Twitter, this may come at a price that many are not willing to pay.
Physicians who choose to advocate for evidence-based public health initiatives to improve population health have to remember, as Drs Schmid and Wolynn pointed out, that their audience, is the general public and not the zealots posting against them. Social media and especially Twitter have never been the place for a full and frank debate about an issue so don’t expect to win any one-on-one arguments there.
Even knowledge or science itself is not a talisman against attackers. Your enemies will use science against you even if it is the science of the pre-print, press release, retracted paper or cherry-picking of evidence. More importantly, as Dr. Frédéric Bouchard, dean of arts and science at the University of Montreal, pointed out at another session during the immunization conference, “we must accept that scientific expertise is not just about facts and methods but also about building trust and working with integrity.”
Unfortunately it is when physicians are pitted against other physicians on social media that discussions often become most heated and upsetting. Many Canadian physicians currently face lawsuits for challenging a colleague who they felt had published inaccurate and potentially dangerous views about COVID-19 treatments. Whether these suits are valid or not they raise the specter of libel chill which can dissuade even the most well-meaning physician advocate from venturing onto social media. But trite though it may sound, truth is an absolute defence against libel in virtually every jurisdiction in Canada.
The reality is that social media is where information is being most widely shared and disseminated these days. And to quote the brilliant English fantasy writer Terry Pratchett “a lie can run around the world before the truth has its boots on.”
Physicians such as Dr. Jennifer Gunter and academics such as Tim Caulfield are proof that people can survive or even thrive in the face of the anti-science movement. “Hide, ban or delete” is an effective method of dealing with comments from those who would mount ongoing personal attacks against you, your family and your motives on social media, as Dr. Wolynn pointed out.
And as the publications of Dr. Schmid and others demonstrate there are effective tactics to counter not just the anti-vaccination movement but any anti-science campaign.
tellAs we move into the critical phase of rolling out vaccines to control the COVID-19 pandemic, physician voices on social media are not just nice to have – they are essential for making certain science-based approaches are applied.
An earlier version of this blog was posted on kevinmd.com
Illustration shows the cover of The Debunking Handbook 2020 written by Dr. Schmid, Dr. Gordon Pennycook from the Hill-Levine School of Business, University of Regina, and others which summarizes the current state of the science of misinformation and its debunking.
A major provincial court has provided strong support for the right of nurses, physicians and other health care professionals to express concerns about healthcare on social media.
Earlier this week, the Saskatchewan Court of Appeal – the province’s highest court – ruled in favour of Carolyn Strom, a nurse who was disciplined by the Saskatchewan Registered Nurses Association after she complained on Facebook about the care her grandfather had received at end of life in a long-term care facility in Macklin, Saskatchewan.
The decision by the nurses association had prompted widespread concern that the regulatory body was infringing on the right of a health care professional to express their views about healthcare.
“Nurses, doctors, lawyers and other professionals are also sisters and brothers, and sons and daughters,” Mr. Justice Brian Barrington-Foote wrote. “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.”
While the appeal court stated regulators have the authority to impose limits, Mr. Justice Barrington-Foote wrote that in this case the nursing association’s actions had an excessive impact on Strom’s right to freedom of expression.
“Ms. Strom posted as a granddaughter who had lost one grandparent and was concerned for the future of another. That fact was front and center for a reader of the posts. Although she identified as a nurse and an advocate, she was not and did not purport to be carrying out her duties as a nurse. She … spoke to the quality of care provided by a distant facility with which she had no professional relationship. The private aspect of the posts was made clear and was significant. Further … the posts have not been shown to be false or exaggerated and, on the face of it, would appear to be balanced.”
The Facebook comments by Strom were posted on Feb. 25, 2015 and she subsequently copied her concerns to the provincial minister of health and opposition leader on Twitter. Some employees of the home long-term care home took exception to the posts and reported them to the nurses association.
On Oct. 18, 2016, she was found guilty of professional misconduct by a discipline committee of the nurses association and ordered to pay a $1,000 fine and $25,000 to cover the cost of the tribunal. She appealed the association’s decision to the province’s Court of Queen’s Bench, but this appeal was dismissed in 2018. The decision by the Court of Appeal came following a hearing which took place almost a year ago in September, 2019.
“Criticism of the healthcare system is manifestly in the public interest,” Mr. Justice Barrington-Foote wrote. “Such criticism, even by those delivering those services, does not necessarily undermine public confidence in healthcare workers or the healthcare system. Indeed, it can enhance confidence by demonstrating that those with the greatest knowledge of this massive and opaque system, and who have the ability to effect change, are both prepared and permitted to speak and pursue positive change. In any event, the fact that public confidence in aspects of the healthcare system may suffer as a result of fair criticism can itself result in positive change. Such is the messy business of democracy.”
The decision noted that having focused solely on the critical portions of Strom’s post, the discipline committee “failed to recognize that her comments were not only both critical and laudatory but were self-evidently intended to contribute to public awareness and public discourse. Ms. Strom spoke to the need for training and of the right of all residents to quality and compassionate care. She spoke to the need for the loved ones of residents in extended care to play a part in the accountability of the system.”
The appeal court said it made no findings about whether those employed at the long-term care home “failed to provide appropriate care to Ms. Strom’s grandparents.”
Days of Past Futures 