Case Scenario

I'm no stranger to social media. In addition to writing content for my practice's Web site and Twitter account, I often post comments on discussion Web sites for physicians. It probably shouldn't have come as a surprise to me when my patients started sending me friend requests on Facebook. Some requests came from patients I have known for a decade or more; others came from patients I have seen only once or twice. On one hand, I'm not concerned about revealing information about my day-to-day activities to patients, and reading their status posts might help me learn whether my patients with diabetes mellitus or heart disease are following my instructions on diet and exercise. On the other hand, I don't know if this would be considered unprofessional or would potentially violate the Health Insurance Portability and Accountability Act (HIPAA). Would it be different if patients wanted to connect with me on more professional networking Web sites, such as LinkedIn? Are there any accepted standards for interacting with patients using social media?

Commentary

First of all, kudos for getting involved in social media with the goal of promoting the health of your patients and collaborating with colleagues. Physicians, in general, have been slow to embrace social media as a way to promote positive professional behaviors, such as disseminating sound medical information, engaging in health advocacy, promoting patient safety and health literacy,¹ and developing medical education innovations. ^2,3 However, you're right to be cautious when it comes to interacting with patients using social media. Medical trainees and professionals have had lapses in judgment when it comes to online postings.^4–6 Some of these incidents have resulted in students being dismissed from medical school, some have led to the loss of jobs, and others have caused embarrassment for persons and institutions.^4,7

In terms of universally accepted standards for interacting with patients using social media, it is kind of like the Wild West. As with any technologic leap in communication methods, social networking Web sites create new scenarios that the medical profession has never dealt with before. This is reminiscent of when e-mail became a common method of communication, and ethical guidelines were developed on acceptable use of e-mail between patients and physicians.⁸

Accepting a friend request from a patient on Facebook could be alluring for several reasons. First, as you mentioned, you could learn things about your patients that could help you manage their medical problems. You might feel flattered that patients think highly enough of your relationship that they would want to be friends with you, and you might believe that it could enhance your therapeutic relationship to be connected in this way. You also might not want to offend a patient by declining or ignoring the request. However, with regard to professional concerns, the main issues are maintaining appropriate boundaries, placing patient welfare first, and complying with ethical and legal obligations to protect patient privacy.

Many people who use Facebook, including physicians, share personal information on their profiles, including off-the-cuff comments, personal photos, links to favorite Web sites, and even play-by-play documentation of their Facebook activity. This represents a wealth of information that is not normally disclosed during the patient-physician encounter. Although some shared banter on mutual interests can help build rapport between physicians and patients, excessive self-disclosure is unlikely to be helpful in the clinical setting, and could lead to boundary violations, sexual or otherwise.⁹ Also, what if you did discover a photograph of your patient, whom you just referred for gastric bypass surgery, competing in a doughnut-eating contest? Would it be appropriate to bring that up at an office visit? What if the patient did not intend for you to see it? Would bringing it up affect your therapeutic relationship?

Beyond the sticky issue of entering a dual relationship with your patient, which an online friendship on Facebook could arguably represent, maintaining patient privacy should be a concern for physicians who have online interactions with patients in public or semipublic online forums. A physician could unwittingly disclose protected health information while communicating online with patients. Also, according to specialists in privacy law, the mere existence of an online patient-physician relationship could, in some cases, represent a HIPAA violation.¹⁰ Having others in your social networking circle realize that one of your Facebook friends is one of your patients could be an issue. Patients may not fully understand the ramifications of extending a friend request. One legal suggestion is to have patients agree to a written disclosure statement before being friends with you on Facebook, if this is the path desired.¹⁰ Clearly, patient privacy law is complex, and few physicians have a firm grasp on all of its intricacies.

There are few guidelines on interacting with patients using social media, although more are likely to come. The American Medical Association published a policy on professionalism in the use of social media, which addresses the importance of maintaining appropriate boundaries in the patient-physician relationship, refraining from posting protected health information online, and separating personal and professional content online.¹¹ The Journal of Medical Ethics has published more specific guidelines urging physicians never to invite a patient to become an online friend, or to accept a friend request from a patient.⁹ If a physician is concerned that declining the invitation might damage the therapeutic relationship, the authors suggest a face-to-face explanation of why this could be unethical.⁹ These guidelines were based primarily on the kinds of interactions typical of recreational social networking Web sites, such as Facebook.

Could an online friendship with a patient be better negotiated on a professional social networking Web site like LinkedIn? Certainly, the amount of personal information would be limited, making excessive self-disclosure and unintended information exchange less of a threat. Although there is still concern for privacy violations, this might be a reasonable option for physicians who have weighed the risks and benefits, and who wish to stay connected with patients on social networking Web sites.