Social media sites such as Facebook, Twitter, and Instagram attract billions of users daily. With the popularity of these sites, it is not surprising that many patients have turned to social media to share their health experiences or to learn more about their medical conditions. Family physicians are in a unique position to provide accurate information about a variety of health topics. By meeting patients where they are on the internet, family doctors can educate the public and support policies to advocate for community health. They can also find an outlet for professional engagement and connection as well as personal creativity.

Yet entering the world of social media can be daunting. Professional society recommendations for social media use tend to be either too restrictive, focusing on what not to do, or too general to provide practical tips. In this article, we explore some best practices and challenges that have emerged as more physicians and patients are using these platforms for health information.

DEFINING YOUR GOALS

The first step in developing a high-performing social media presence is determining your goals. The more well-defined your objectives, the easier it will be to identify an audience, decide what to share, and measure effectiveness. The social media aims for family physicians can be as diverse as family physicians themselves. The most basic aim is connecting with current patients, and a previous article in FPM discussed how family physicians can do this.¹ Additional goals include the following:

• Providing health education to the public. Education can focus on general topics such as fitness or wellness, or on a topic in which you have particular interest or expertise. How you distribute content on these topics can vary from simply sharing links to news or research articles (along with your perspective or commentary) to producing original content in the form of infographics, blog posts, podcasts, or videos. With the latter approach, social media can become a creative outlet and perhaps even reduce burnout.

• Promoting your practice. A strong social media presence can help you recruit patients to your office, retain current patients, and have more control over your online reputation. For example, when patients search for a physician online before scheduling an appointment, seeing a positive social media presence can alleviate isolated negative reviews they may find.

• Connecting with other physicians. In many ways, social media has become the new “doctors’ lounge.” Due to the proliferation of hospitalists and electronic health records, family physicians have fewer opportunities to interact informally with subspecialists than in the past. Social media has allowed many physicians to engage with prominent subspecialists around the world in a virtual doctors’ lounge and participate in multidisciplinary conversations in scheduled chats or asynchronous question-and-answer sessions. For example, Dr. Lin has participated in discussions with specialists on Twitter about evidence and best practices for chronic pain management, prostate and lung cancer screening, infectious disease prevention, and interventional cardiology. As in real life, specialists do not always agree with each other or their own society’s practice guidelines. Nonetheless, these debates are helpful in understanding the “hot topics” in the field and the implications for primary care patients.

• Advocating for a cause. You can use social media for advocacy in several different ways: listening to and amplifying the stories of those with particular experiences, informing people of issues they were previously unaware of, organizing supporters for a specific cause, and pushing for more direct actions. Sometimes, simply sharing a day-to-day experience in health care can have a meaningful impact. For example, a story about the difficulty of obtaining a much-needed prior authorization for a patient can initiate a larger conversation on social media about insurance companies and barriers to effective care. Additionally, physicians use social media to mobilize around community issues, ranging from local concerns like a hospital closing to larger discussions about health equity. This method of advocacy also allows physicians to capture timely issues in the news cycle and offer the physician perspective. Finally, family physicians can influence public policy. While fact and data will legitimize particular issues, patient stories are often what legislators and staffers remember and what compel them to act. The physician can use the story as a springboard to writing and publicizing an editorial or letter to the editor, meeting with a legislator, or helping organize a community event.

Regardless of your social media goal, starting with a clear intention will help you build an audience and transform an existing social media presence into a coherent, authentic brand.

GROWING YOUR AUDIENCE AND BRAND

Once you have identified your goals, you must consider your audience. For example, to disseminate accurate medical information, you want to reach health professionals and the general public while following and interacting with the top scientific minds in the field to be aware of current findings. If you are trying to create social or political change, then your audience is health care leaders, policymakers, political leaders, and patients who inform their work.

The tone and content of your social media presence should align with your objectives and the community you are building to accomplish those objectives. It’s a good idea to start by following thought leaders who are already achieving similar goals to see what they are doing on social media. Who do they follow? What sort of content do they share? What tone of voice do they use (casual, scholarly, etc.)? How often do they post and on what platforms (Facebook, Twitter, Instagram, LinkedIn, etc.)? What hashtags, podcasts, blogs, or publications are prominent in their field? As you better understand the landscape around your areas of interest, you can better hone your message.

Knowing your audience also involves taking the time to listen to the communities that you are trying to join. For a doctor, this means listening to patient advocates equally if not more than other physician leaders. Connecting with patients outside the treatment setting and the doctor-patient relationship enables a wider perspective of the healthcare-industrial complex in which we exist.

Having a clear intention, audience, and message will ultimately lead to a clear brand. By nature of our work and expertise, physician voices can attract attention even with just a tweet or two, but a social media following really grows when a doctor has a clear brand on which followers can depend. Having a clear brand is useful for you too, as it helps reduce the “noise” so you can focus on the conversations that matter to you and accomplish your objectives. A high follower count or “going viral” isn’t necessarily the sign of an effective brand; if your purpose is advocacy or engaging in the latest research, it is often more important to reach the target audience than to reach a high number of people. That said, the more you develop your brand, the more likely that your social media following will grow, which could lead to professional opportunities such as paid speaking engagements, writing opportunities, or sponsorships.

Much has been written about what a social media “brand” should entail, but it comes down to authenticity. In an increasingly technological world, people crave human connection, so the more dimensions of yourself you can share (including professional and personal aspects of your life), the more authentic your brand will be. If you like sharing news stories mixed with occasional photos of your dog, don’t be afraid to do so. If you have a passion for Star Wars and medicine, feel free to express it. Do what feels most authentic to you.

As you grow into your brand, the content you share will begin to develop certain themes that followers will learn to expect. Once you become known for something, it becomes part of your brand. Your goals and identity may evolve over time, but the key is staying true to yourself, what you care about, and what aligns most closely to your aspirations for being on social media.

AVOIDING COMMON CHALLENGES

If you’ve used social media for any length of time, you’ve probably witnessed friends, family, or colleagues who have gotten into trouble because they failed to follow basic social norms. To avoid common social media challenges as a physician, the following norms can be helpful.

Be professional. Physicians face unique challenges being on social media, in part because the lines between their professional and personal lives can become blurred. Being personable is encouraged; being unprofessional is not. Physicians represent their profession in the way they treat others and in the quality of the information they provide. They should continue to operate under the professional principle of first doing no harm.

Refrain from offering medical advice to individuals on social media. It is better to share general educational tips than specific medical advice and, where indicated, it may be worth explicitly noting this to your followers. It is difficult to obtain detailed and verifiable information from online accounts, so you can’t always be sure who you’re talking to online. Furthermore, given the privacy concerns of sharing any personal health data on social media, doctors should discourage others from exposing themselves to unnecessary privacy risks by sharing intimate information.

Be careful when posting about patients. Everything posted on social media is stored forever and owned by the company that runs the platform. Always think before posting: Is this something patients or their family members could see and recognize as their own information? Is this your information to share? The Health Insurance Portability and Accountability Act (HIPAA) should be a starting point to consider before sharing sensitive details about patients online. Additionally, the Health Information Technology for Economic and Clinical Health (HITECH) Act allows the Office of Civil Rights (OCR) to investigate and financially penalize a hospital or practice for HIPAA violations.² Furthermore, the 1996 Communications Decency Act amended with the Internet Freedom and Family Empowerment Act protects internet service providers and interactive computer services from being held liable for indecent or defamatory content posted by third-party users.² Physicians should be aware of these laws as they navigate using social media.

Most health professionals understand that discussing specific cases even without using a patient’s name may reveal enough information for a third party to recognize a patient. To protect patient identity, exploring a medical condition in generalities or using fictionalized accounts is recommended rather than using a specific case. If you need to use an actual case, especially where a specific image or video is involved, provide informed consent and invite the patient, guardian, or power of attorney to sign a media release prior to publication on any online platform. Once the information is shared, the patient and the physician lose control over how it may be circulated, so it is important to take the time, separate from a medical or procedural consent to care, to help the patient understand the risks and benefits of such an act.

As people use social media and follow health professionals online, physicians must not only be careful about posting details that could violate HIPAA but also make sure the patient descriptions they use are not disrespectful. Sensational posts may generate follower engagement, but as members of the medical profession, we hold ourselves to a higher ethical standard and should not exploit a patient encounter. Careless posts can disrupt the trust between a patient and physician.

Be selective when interacting with patients. Questions about whether to “friend” or “follow” your patients or accept their connection requests on social media are inevitable, but these issues are not new. Long before the introduction of the internet, doctors who live in small towns and communities have been acquaintances and friends with patients in real life and have had to navigate these boundaries. The anonymity and ubiquity of relationships on social media, where individuals have many more “friends” and connections than they could ever truly know, could tempt some physicians to befriend more people, patients included, than they typically would. Some doctors make a point of never friending or following patients on social media, while others initiate requests and accept everyone. Of course, you should follow your institution’s policies on social media and professionalism, but we advise being selective in who to friend or follow on social media, whether they are patients or not. Whether in real life or digital life, doctors have to determine their own boundaries and comfort level when it comes to engaging with patients outside of the exam room.

Protect against misinformation. Physicians on social media have a professional responsibility to ensure the accuracy of the health-related content they create or share. Health professionals can be as vulnerable to misinformation as laypersons, particularly when they share information initially posted by someone else. Be wary of sharing an unreferenced statement or statistic that another user has shared. If you cannot verify it, either don’t share it or add a caveat that the information has not been personally verified. It’s better to share content that includes a link to an authoritative source.

Limit screen time. Family physicians have multiple personal and professional commitments, so it is important when considering your social media goals to also consider how much time you can dedicate to using these tools. Building an online brand can require a substantial time commitment, especially in the start-up stage. When Dr. Lin began his blog Common Sense Family Doctor in 2009, his goal was to post twice per week, which required around three to four hours per week, not including additional time spent reading and commenting on other blogs and social media accounts. He gradually reduced the posting frequency to two to three times per month after about four years, when the blog was well established. Today, it receives an average of 20,000 page views per month.

In this quickly evolving social media world, Twitter has become a place where family physicians can develop their online brand without spending a lot of time. Dr. Sevilla has attracted close to 30,000 followers on Twitter by sharing the latest health news (spending approximately 15 minutes daily scanning for hot topics in health news and posting them to Twitter), sharing information at conferences (approximately one hour daily at the conference posting pearls from lectures and retweeting other attendees’ posts), and participating in Twitter chats (approximately one hour weekly in which a moderator poses several questions around a theme, providing a great opportunity to share your point of view and network).

While social media can be helpful for many purposes, these platforms also are designed to be addictive. Algorithms learn what users like and create feeds of information to encourage them to keep checking the sites. Growing a community and purpose on social media can be fulfilling, but it can disrupt the physician’s initial intent of joining the platform or pursuit of other life passions. Like younger users, adults should limit screen time, disconnect as needed, and allow time for activities in real life or reflection. Instead of filling up time with scrolling through social media, make sure you are taking appropriate breaks and exploring curiosity, creativity, and innovation in other ways as well.

Follow institutional policies. Especially for those low in their institutional hierarchy, from medical students to entry-level employees, it may feel as though you cannot participate publicly in social media without violating institutional policies. In most cases, that isn’t true, but before starting, you should know your employer’s social media policies. Some institutions are more conservative than others. Most simply request that employees remain professional in their social media presence and clearly state that the opinions shared are personal and do not reflect those of the employer.

In most situations, it comes back to the goals of using the platform. For those looking to further an advocacy agenda, individual voices and stories are important. Institutions, whether they are public or private entities, may limit individual rights to free speech depending on the type of speech involved and an employee’s position (e.g., if it contradicts the employer’s position). When in doubt, seek guidance from a local mentor to sort out the specifics of the situation. Remember that nothing we do in public is apolitical. For example, by overlooking certain political content, family physicians may be implicitly supporting the status quo. You will have to balance staying true to your objectives within the local political-organizational landscape where you work. Otherwise, you may have to find another job.

Avoid conflicts of interest. Economic gain can be a reason that some physicians get involved in social media. While an increased volume of patients can be a benign effect of social media involvement, potential conflicts of interest may also arise. Sponsored content, also known as influencer or native marketing, is often paid content from a third party, but it can appear to be coming directly from the individual (in this case, the family physician). For example, a marketing agency could target physicians who generally speak about prenatal vitamins, asking them to publicly support a pharmaceutical company’s brand. For social media “influencers,” sponsored content can be an important revenue stream, but for family physicians, sponsored content poses an ethical conflict of interest.

The Federal Trade Commission now has guidelines on transparency around sponsored content. If social media influencers are getting paid for mentioning a product or even an idea, they must reveal it. Marketing partnerships should not be hidden in a small hyperlink. For physicians, sponsored content should be disclosed similarly to other conflicts of interest. For most physicians, this won’t be an issue, but those with 5,000 to 25,000 followers on a platform may be approached to post sponsored content.

It’s also important to be aware of the ethical implications of making certain endorsements or statements on social media. Medical ethics encompass respect for autonomy, beneficence, nonmaleficence, and justice. These ethics could be violated if a physician, for example, sponsored a product known to cause harm in certain populations but did not disclose that fact. In addition, given the power dynamics of the physician-patient relationship, a physician’s patients may feel pressured to purchase a product their physician endorses online. While there is limited case law on health professionals’ online endorsements of questionably effective products, high-profile physicians like Dr. Oz (Mehmet Oz, MD) have been called before Congress for deceptive marketing of supplements.³

Family physicians who accept payment for their content should consider if the content is consistent with current standards of care and evidence-based medicine. Ultimately, this is a personal decision, but it could impact a family physician’s reputation. Additionally, family physicians should be aware of laws surrounding promotion.

BUILDING TRUST ABOVE ALL

Social media is a valuable tool that can be used to educate, collaborate, and advocate. Before jumping in or reassessing your use, it’s a good idea to define your goals, listen to the conversation, develop an audience, and think about how to present an authentic online persona. Be professional in your interactions with patients and the public, be judicious about sharing patient stories, obtain informed consent before sharing information involving patients, understand your employer’s social media usage policies, and be careful with potential conflicts of interest. As more physicians and patients use these sites, we have the obligation to present evidence-based information respectfully and transparently in order to build and maintain trust.