Clinicians Warned About Social Media #BoundaryViolations

Deborah Brauser

June 12, 2019

SAN FRANCISCO — As physicians' social media use has increased, so have concerns about ethics, privacy, and maintaining appropriate boundaries between clinicians and their patients.

An interactive session held here at the American Psychiatric Association (APA) 2019 annual meeting entitled "#BoundaryViolations" explored these issues in a bid to encourage clinicians to consider their online image and responsibilities.

During the crowded session, which was conducted by clinicians from the Walter Reed National Military Medical Center in Bethesda, Maryland, 74% of attendees said they regularly use two to five social media platforms. Instagram was the most used platform, followed by Facebook. In addition, 92% of the attendees reported they were "confident" with their use of these types of platforms.

Interestingly, 27% said they had looked up a patient on social media to aid clinical decision making. However, 46% said they had done so out of curiosity. The latter goes against recommendations by the APA's Ethics Committee that were published online earlier this year. The committee noted that curiosity is not a valid reason for conducting an Internet search regarding patients and could lead to boundary violations.

"It is clear that social media is impacting our patient population, and we should pay extra attention to how it affects their mood and anxiety, but also to how we choose to interact with them and how they choose to interact with us," session presenter Captain Robert J. DiFilippo, DO, said.

"We need to adapt to this changing ecosystem to truly understand all the needs of the patients in our care while also [learning about] best ethical practices regarding the online patient-provider relationship," he added.

Awareness Is Key

Commenting for Medscape Medical News, John Torous, MD, director of the Division of Digital Psychiatry at Beth Israel Deaconess Medical Center, Boston, Massachusetts, noted that clinicians shouldn't be afraid of using social media, but awareness is key.

"It's realizing that everything you post is going to be public. Keep in mind: is this something you would be happy to show your patients, your mother, or your residency director? If you keep that in mind and use it in a professional sense, no inside jokes or sarcasm, you won't go too wrong," said Torous, who was also recently named chair of the APA's Health and Technology Committee.

"It's defining, 'what is my professional message?,' and determining how you're reaching an audience with that message. It's keeping a goal in mind. You don't need to sometimes mention political or religious beliefs to get your point across," he added.

DiFilippo noted that use of social media among young adults increased from 12% in 2005 to 90% in 2015, and global Internet use rose 566.4% between December 2000 and June 2012.

He said that social media offers many benefits — it can help maintain relationships or form new connections and has been associated with increased life satisfaction.

In addition, moderate social media consumption can be especially helpful in dealing with loneliness or other issues in populations such as retired older adults or military veterans.

However, it has also been shown to increase symptoms of depression and anxiety, as well as social comparison — the so-called FOMO syndrome (fear of missing out).

Clinicians need to remember that everyone leaves a digital footprint, Lieutenant Maria Aguilar, MD, noted during her session presentation. "So all of your triumphs and failures live online. The Web means the end of forgetting," she said.

"This is important for psychiatrists because, whether we realize it or not, there are some self-disclosures that we are making, whether voluntary or involuntary," Aguilar added.

She noted that many healthcare providers have personal as well as professional information on their social media accounts. For instance, she said, on her personal Instagram account, she has posted photos of cats and her wedding but has also used it to "lend my voice" to causes that are important to her.

Other providers use social media strictly for professional reasons, including establishing an online presence to provide education and maintaining connections to colleagues.

However, examples cited by Aguilar of physician violations of online professionalism have included YouTube videos of doctors making fun of patients, photos posted of doctors drinking, and reports of doctors posting specific patient information.

Frequency of Use

During live polling at the start of the session, attendees were asked how often they use/check/post to social media. Thirty-six percent of respondents reported they check social media every day, and 29% said they check accounts multiple times per day.

In addition, 47% of attendees said they regularly use two social media platforms, 27% said three to five, 20% said one, and only 7% reported they had no social media accounts.

In addition, 36% of respondents said a patient had reported looking up the clinician's social media accounts, and 18% said a patient had reached out through social media, either through a public post or direct message.

Asked how they responded if contacted by a patient through social media, the number 1 answer given by the attendees was "ignore."

Aguilar noted that a recent national survey of 48 boards showed that 56% had issued serious disciplinary measures, including license restrictions, suspension, or revocation, because of violations of online professionalism.

The most common violations were inappropriate patient communication, including sexual misconduct; prescribing via the Internet without an established clinical relationship; and a misrepresentation of credentials online.

The American Medical Association issued online medical professionalism guidelines in 2012 that include using privacy settings, maintaining appropriate boundaries, and recognizing that posts can negatively affect one's career and reputation.

The American College of Physicians and the Federation of State Medical Boards have also issued online guidelines, which include keeping personal and business accounts separate, to "pause before posting," and to not contact past or current patients.

Psychiatrists often face "the same ethical dilemma that the country doc faces. In these small towns, there's pervasive incidental contact and inevitable self-disclosure," Aguilar said. The term for this is "small world ethics."

"You shop at your patients' stores and you treat family members of friends, so you have unavoidable multiple relationships. As in this situation, psychiatrists face multiple challenges in maintaining professional boundaries," she said.

Doctor, Patient Searches

In a study published in 2016, 45% of 238 former and current patients of psychotherapists reported obtaining information about a provider from various sources; 80% of these patients obtained the information from the Internet.

"Patients with a history of personality disorder appeared to engage more frequently in therapist-targeted googling, or TTG," Aguilar said. TTG is a form of provider self-disclosure, even though it's client initiated, she added.

On the other hand, a study published in 2018 showed that 16% of practicing physicians in 2010 reported having visited a Web page containing an online profile of either a patient or a patient's family member (patient-targeted googling [PTG]).

Reasons that have been given for PTG include habit, curiosity, and voyeurism. Other reasons include forensic evaluation, suicide-risk assessment, and concern for doctor shopping.

In 2017, the APA's Ethics Committee noted that "performing targeted internet searches on a patient is not, in and of itself, unethical." However, this type of search "should only be done in the interests of promoting patient care and well-being." It is also important to consider how this could influence treatment decisions; and, in the name of transparency, a clinician should disclose to a patient that such a such search took place, the committee adds.

In its April article, the committee specifically focused on Internet searches for patient information. They note that these searches could lead to boundary and trust problems, should only be done after obtaining consent from the patient, and could yield unreliable information.

"Psychiatrists are encouraged to explore their own motivations for, and ethical issues related to, the Internet search for personal information about patients," they write.

Following the session, Torous noted that although each case is unique, a good rule for psychiatrists to keep in mind if looking up patient information online is to first tell the patient, or even look at the information with them.

"Getting informed consent of information you're accessing is important. You can access it without consent so easily, but to maintain a professional relationship, get consent. It comes down to trust, and you really need patients to trust you, especially in psychiatry, where they have to disclose things they wouldn't disclose to most other people," he said.

"Anything that erodes that trust or can potentially erode that trust is a cliff you want to stay away from," Torous added.

He noted that after getting consent, going through a patient's profile with the patient can lead to meaningful conversations about issues such as whether an individual is presenting themselves in a truthful manner. "There's where your therapeutic value is. It starts a conversation that brings up new things and helps explore new areas," Torous said.

In cases in which patients may make online threats, Torous said psychiatrists would have "a duty to warn." But even in such scenarios, he noted that there are "a lot of gray areas that haven't been defined yet," largely because technology is evolving so rapidly.

"Because policies differ from universities to healthcare systems and state to state, it's hard to make sweeping statements," he said.

Balancing Act

Also asked to comment, Gregory Dalack, MD, professor and chair of the Department of Psychiatry at the University of Michigan (UM), Ann Arbor, told Medscape Medical News that he's "a late bloomer" to social media because of concerns over wanting to keep clear boundaries and not wanting to "put myself out there in ways that could be misinterpreted."

Dalack, who is also treasurer of the APA, created a Twitter account in January in order to get the word out about the work being done by his department at UM "and to try and provide information to folks who may be looking for relatively well-balanced and curated information. So it's a pretty professionally focused activity for me," he said.

He noted that although he's providing information that will hopefully help patients, "it's important to be clear that you don't make a diagnosis or even speculate at all with limited information."

Regarding online searches of patients, Dalack said there are times when some of the information can be informative, but it can also be subject to overinterpretation.

"I think the message we try to give is, you can look at a variety of data, but you want to make an inference based on the fullest picture you can get, rather than leaping to conclusions based on limited information," he said.

"It's a balancing act, and you want to be as transparent as possible with the patient while you're trying to put together as complete a picture as possible. In some situations, you may go to family members to get information. [Social media] is one source of information but shouldn't be the only source," Dalack concluded.

The presenters have disclosed no relevant financial relationships. They note that the views expressed in the presentation do not reflect the official policy of the Department of the Army/Navy/Air Force, the Department of Defense, or the US Government.

American Psychiatric Association (APA) 2019: Presented May 18, 2019.

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